Ian Govias Gaynor Mitchell - Asthma Education Principles and Practice For The Asthma Educator.-Springer Nature (2021)

Asthma
Education
Principles and Practice
for the Asthma Educator
Ian Mitchell
Gaynor Govias
Second Edition
123
Asthma Education
Ian Mitchell • Gaynor Govias
Asthma Education
Principles and Practice
for the Asthma Educator
Second Edition
Ian Mitchell Gaynor Govias
University of Calgary Edmonton, AB
Calgary, AB Canada
Canada
1st edition: © Authors 2005

ISBN 978-3-030-77895-8 ISBN 978-3-030-77896-5 (eBook)
https://doi.org/10.1007/978-3-030-77896-5
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Preface
To educate educators! But the first ones must educate themselves! And for these I
write. (Friedrich Nietzsche)
Much has changed since 2005 in the fields of asthma and asthma education,
when this book was first published as Asthma Education – Principles and
Practice [1]. While the principles and theory underlying asthma remain much
the same today, new equipment, guidelines, and medications have since
appeared, and so we felt it appropriate to release this second edition. Some of
the new medications belong to the paradigm of precision health and promise
to be as great a revolution in asthma care as inhaled corticosteroids when they
were introduced.
We aimed for clarity in our writing, using all the tools of the English lan-
guage. We used American spellings and American trade names for medica-
tions and devices. Sadly, manufacturers, selling the same medication and
device, often use different names in different countries. If you find some of
the spelling unfamiliar, we suggest you consult a national medical
organization.
The first edition was ahead of its time – it was published when the profes-
sion of asthma education was in its infancy. Regulatory organizations were
just being set up, and only a handful of trained asthma educators existed in
America. There are more educators today, as well as institutions that formally
train asthma educators, but comprehensive texts written specifically for
asthma educators are still rare. Asthma Education – Principles and Practice
remains the only text written specifically for asthma educators on asthma
education.
This second edition – which we call “Asthma Education: Principles and
Practice for the Asthma Educator” – has been updated and made comprehen-
sive, and now includes a part on COVID and asthma. We believe it is still the
only textbook an asthma educator will require. It provides the necessary med-
ical knowledge, describes medications and equipment in use, and – most
importantly – answers the vital question that conscientious asthma educators
everywhere ask themselves: “I have all this knowledge. Now how do I com-
municate it effectively to my patients?” The cooperative relationship between
those with asthma and their professional advisers – which we have long advo-
cated – is becoming the norm in all areas of healthcare.
v
vi Preface
If you are an experienced asthma educator, and now have the immensely
rewarding job of teaching new educators, we hope this book will make your
job a little easier. We believe it will also make an excellent text and reference
source.
The goal of education is to meet the needs of the individual. In asthma, the
goal is to help those with asthma to self-manage their illness. But the educa-
tor also has an unstated goal. Dr. Richard S. Irwin [2], in a convocation speech
to the American College of Chest Physicians, read aloud their pledge on
patient-focused care (PFC). It states that:
PFC is compassionate, is sensitive to the everyday and special needs of patients and
their families, and is based on the best available evidence. It is interdisciplinary, safe
and monitored. To ensure the provision of PFC in my professional environments, I
shall willingly embrace the concepts of lifelong learning and continuous quality
improvement.
It is a pledge that we believe every aspiring asthma educator should take and
strive to meet, for it will make the difference between being merely compe-
tent – and being outstanding and effective.
References
1. ISBN 1-896291-19-8.
2. Irwin RS. Patient-focused care: the 2003 American College of Chest Physicians
Convocation Speech. Chest 2004;1125: 1910–12.
Calgary, AB, Canada Ian Mitchell

Edmonton, AB, Canada Gaynor Govias
Acknowledgments
This book could not have been written without the guidance and support of
many individuals over many, many years. The authors welcome the opportu-
nity to specially thank the people who helped them along the sometimes-
difficult path from inspiration to publication.
The influence of wise mentors, whether at the start of a career or at some
stage during it, cannot be over-emphasized. Ian Mitchell’s interest in asthma
was stimulated, first by Drs. Ian Grant and Hamish Simpson in Edinburgh,
and then by Dr. Henry Levison in Toronto, all of whom provided a first-rate
grounding in the scientific aspects of lung disease and asthma. Further educa-
tion came from the nurse educators and the psychosocial team at the Alberta
Children’s Hospital, Calgary, Canada.
Gaynor Govias was encouraged and supported by Dr. G Fred MacDonald,
an early advocate for patient education who set a very high standard in the
field. The advice and encouragement she received from Dr. Tom Plaut, Dr.
Elliot Ellis, Dr. Kathy Conboy-Ellis, and Dr. Stanley Galant was also
invaluable.
A special thank you to Kenneth Govias who looked after the technical
aspects of the manuscript; offered helpful advice, support, and wise counsel;
read and re-read much of the text; and kept us on schedule.
For the use of their diagrams, photographs, and tables, our thanks go to the
Asthma Education Clinic Ltd., AstraZeneca Canada Inc., Boehringer-
Ingelheim Canada, Medical International Research, Merck Canada Inc.,
Mylan Pharmaceuticals ULC, Pari Respiratory Equipment, and Teva Canada.
For both authors, some of the best teachers were the people with asthma
and their families. Because of them, both authors improved (and continue to
improve) their knowledge and skills, and have come to appreciate that patients
are unique individuals whose medical treatment must be compatible with
their goals in life. Our special thanks to them.
vii
Contents
Part I Asthma: The Fundamentals
1 Asthma and Asthma Education: The Background �� 3

1.1 Introduction�� 4
1.2 What Is Asthma? �� 5
1.2.1 Symptoms �� 5
1.2.2 Definitions�� 7
1.3 Significance of Asthma �� 8
1.3.1 Overview�� 8
1.3.2 Morbidity�� 9
1.3.3 Mortality �� 11
1.3.4 Costs�� 12
1.4 Etiology of Asthma �� 15
1.4.1 Allergy and Asthma�� 15
1.5 Genetics and Environment�� 16
1.5.1 Phenotype and Genotype Correlation �� 16
1.5.2 Environmental Issues�� 17
1.6 Approaches to Asthma�� 20
1.6.1 Guidelines �� 20
1.6.2 NHLBI Guidelines�� 20
1.6.3 Pediatric Guidelines�� 23
1.6.4 COVID-19 and Asthma�� 24
1.6.5 Organization of Care�� 25
1.7 Education of Persons with Asthma �� 27
1.7.1 The Issues�� 27
1.7.2 Role of the Asthma Educator�� 29
1.7.3 Skills of the Asthma Educator�� 30
1.7.4 Essential Qualities of the Educator �� 31
References�� 33
2 Lung Structure and Function �� 39
2.1 The Respiratory Tract �� 40
2.2 Parts of the Respiratory Tract �� 40
2.2.1 Nose�� 40
2.2.2 Mouth and Pharynx�� 41
2.2.3 Larynx �� 41
2.2.4 Tracheobronchial Tree Including Alveoli �� 41
ix
x Contents
2.2.5 Histology of the Airways�� 43

2.2.6 Rib Cage and Diaphragm�� 44
2.3 The Nervous System and the Lungs �� 45
2.4 Control of Breathing �� 46
2.5 Defense Mechanisms of the Lungs �� 48
2.5.1 Specific Defenses: Immunological Mechanisms�� 48
2.6 Lung Changes and Pathophysiology of Asthma �� 50
2.7 Conclusion�� 54
2.8 Background Reading�� 54
References�� 54
3 Measurements of Lung Function�� 55
3.1 Overview�� 57
3.2 Lung Volumes and Capacities�� 57
3.2.1 Volumes�� 58
3.2.2 Lung Capacities�� 59
3.2.3 “Normal” or “Predicted” Values �� 59
3.3 Spirometry�� 62
3.3.1 FEV1, FVC, and FEV1/FVC�� 65
3.3.2 Flow-Volume Loops�� 66
3.3.3 Bronchodilators in Pulmonary Function Testing�� 70
3.3.4 A Pulmonary Function Test and Its Interpretation�� 71
3.4 Measures of Lung Function�� 71
3.4.1 Peak Flow Measurement�� 71
3.4.2 Other Measures of Lung Function�� 77
3.5 Bronchial Challenge Testing�� 80
3.5.1 Methacholine and Histamine Challenge �� 80
3.5.2 Exercise Testing�� 81
3.5.3 Inspired Cold Air�� 83
3.5.4 Ultrasonic Distilled Water�� 83
3.5.5 Adenosine 5’-Monophosphate (AMP)�� 83
3.6 Other Testing Methods�� 83
3.6.1 Bronchoalveolar Lavage (BAL)�� 83
3.6.2 Induced Sputum�� 84
3.6.3 Exhaled Breath Condensate (EBC)�� 84
3.7 Oxygen Saturation�� 85
3.8 Pulmonary Function Testing in Infants
and Preschool Children �� 85
3.8.1 Pulmonary Function Testing in Infants�� 85
3.8.2 Pulmonary Function Testing in Preschool
Children�� 86
3.9 Pulmonary Function Testing of Adults Unable
to Do Standard Spirometry �� 86
3.10 Quality Control �� 87
3.11 Application�� 88
References�� 90
Contents xi
4 Clinical Presentation of Asthma �� 95

4.1.1 Symptoms: Overview�� 97
4.1.2 Detailed History�� 97
4.1.3 Physical Examination�� 99
4.2 Investigations: Spirometry�� 103
4.2.1 Other Investigations�� 103
4.2.2 Trial of Therapy�� 104
4.3 Asthma Severity�� 104
4.3.1 Classification of Severity Before Treatment �� 107
4.3.2 Risk Domain �� 108
4.4 Patterns of Asthma�� 109
4.4.1 Important Factors Contributing to Severity�� 112
4.4.2 Occupational Asthma�� 115
4.5 Life-Threatening Asthma�� 116
4.5.1 Severe Acute Asthma (Status Asthmaticus)�� 116
4.5.2 Brittle Asthma, Catastrophic Asthma�� 117
4.6 Differential Diagnoses�� 117
4.6.1 Wheeze and Lung Disease�� 117
4.6.2 COPD and Asthma�� 118
4.6.3 Hyperventilation �� 118
4.6.4 Vocal Cord Dysfunction (VCD)�� 119
4.6.5 Bronchial Obstruction�� 119
4.7 Time Course of Events in Asthma�� 120
4.7.1 Response to Exercise�� 120
4.7.2 Response to Allergens�� 120
4.7.3 Response to Viral Infection�� 120
4.8 Diagnostic Problems in Asthma�� 121
4.8.1 Age-Related Asthma �� 121
4.9 Sex and Gender Differences in Asthma�� 124
4.10 Avoiding Delays in Diagnosis�� 125
4.11 Monitoring Asthma �� 126
4.11.1 Fraction of Exhaled Nitric Oxide (FeNO)�� 127
4.12 Referral to a Specialist�� 127
References�� 128
5 Environmental Issues in Asthma Management�� 131
5.2 Environmental Issues and Common Triggers of Asthma�� 133
5.2.1 Outdoor Allergens�� 133
5.2.2 Indoor Allergens�� 135
5.2.3 Irritants�� 139
5.3 Ingested Allergens�� 140
5.3.1 Oral Allergy Syndrome �� 142
5.3.2 Food Additives�� 142
5.4 Non-allergenic Triggers or Irritants�� 143
5.4.1 Cold Air�� 143
5.4.2 Exercise�� 144
xii Contents
5.4.3 Emotion�� 144

5.4.4 Viral Infections�� 144
5.4.5 Medication Sensitivity�� 144
5.5 Exposure Reduction and Avoidance Techniques�� 146
5.5.1 Pollen�� 146
5.5.2 Mold�� 148
5.5.3 Dust and Dust Mites�� 149
5.5.4 Cockroach Allergen�� 151
5.5.5 Pet Allergen�� 151
5.5.6 Rodent Allergen�� 153
5.5.7 Food Allergen�� 153
5.5.8 Medications�� 154
5.5.9 Insect Allergen�� 154
5.5.10 Irritants�� 155
5.5.11 Viral Infections�� 156
5.5.12 Cold Air�� 156
5.5.13 Exercise�� 157
5.5.14 Latex �� 158
5.5.15 Conclusion�� 158
5.6 Identification of Triggers�� 159
5.7 Home Assessment �� 159
5.7.1 Smoking�� 161
5.7.2 Vaping �� 162
6 Medications Used in Asthma Management �� 175
6.2 Principles of Medication Use�� 178
6.3 Available Medications: Broad Categories of Use �� 179
6.4 Quick-Relief Medications (“Rescue Medications”) �� 180
6.4.1 Short-Acting Beta-Agonist (SABA)
Bronchodilators�� 180
6.4.2 Short-Acting Anti-cholinergic Bronchodilators�� 181
6.4.3 Systemic Corticosteroids�� 181
6.5 Long-Term Asthma Control Medications �� 183
6.5.1 Inhaled Corticosteroids (ICS) �� 183
6.5.2 Long-Acting Beta-Agonists (LABA)�� 185
6.5.3 Long-Acting Muscarinic Antagonists (LAMA)�� 185
6.5.4 Combination Products�� 186
6.5.5 Leukotriene Receptor Antagonists (LTRA)�� 186
6.5.6 Immunomodulators and “Precision Health” �� 188
6.5.7 Long-Term Systemic Corticosteroids �� 193
6.5.8 Theophylline �� 194
6.5.9 Cromolyn and Nedocromil �� 196
6.6 Other Medications Used in Asthma�� 197
6.7 Immunotherapy in Asthma (“Allergy Shots”)�� 197
6.8 Low Evidence-Based Medications as Treatment Options�� 206
6.8.1 Approach to the Use of These Medications�� 206
Contents xiii
6.9 Role of Bronchial Thermoplasty in Treatment �� 206

6.10 Concern About Side Effects: General Approach�� 207
6.11 Classification of Severity After Treatment�� 209
6.12 Step Approach to Asthma Management�� 211
6.13 Goals of Therapy�� 214
6.14 Quality-of-Life Scores�� 215
6.15 Conclusion�� 217
7 Inhalation Devices Used in Asthma�� 223
7.1.1 Metered Dose Inhalers (MDIs) �� 225
7.1.2 Spacers and Valved Holding Chambers�� 230
7.1.3 Dry Powder Inhalers (DPIs)�� 235
7.1.4 Nebulizers �� 245
7.1.5 Choice of Inhaler Devices�� 248
7.1.6 Application�� 250
8 Special Situations in Asthma�� 255
8.1 Special Situations in Asthma�� 256
8.2 Pregnancy�� 256
8.3 Asthma in Older Adults�� 261
8.4 Diabetes�� 265
8.5 Surgery and Anesthesia�� 265
8.6 Occupational Asthma�� 266
8.7 Obesity�� 268
8.8 Immunization/Vaccination�� 272
8.9 Smoking�� 272
8.10 Competitive Athletes�� 276
8.11 Non-asthma Medications and Asthma�� 277
8.11.1 Aspirin Sensitivity�� 277
8.11.2 Sulfite Sensitivity�� 278
8.11.3 Antihistamines�� 279
8.11.4 Over-the-Counter Medications �� 281
8.12 Direct-to-Consumer Advertising (DTCA):
Advantages and Disadvantages�� 283
9 Comorbidities in Asthma�� 291
9.1 Comorbidities and Their Treatment�� 292
9.2 Contact Dermatitis�� 292
9.3 Atopic Dermatitis and Eczema �� 293
9.4 Rhinitis, Sinusitis, and Rhinosinusitis�� 293
9.4.1 Rhinitis�� 293
9.4.2 Sinusitis�� 297
9.5 Nasal Polyps�� 299
9.6 Gastroesophageal Reflux�� 299
9.7 Vocal Cord Dysfunction (VCD)�� 302
xiv Contents
9.8 Asthma-COPD Overlap (ACO)�� 304

9.9 Obstructive Sleep Apnea�� 305
9.10 Bronchopulmonary Aspergillosis (ABPA)�� 307
9.11 Depression�� 309
9.12 Acute, Severe Acute, and Life-Threatening Asthma�� 310
9.12.1 Classification of Severity of Acute Asthma�� 312
9.12.2 Treating Asthma in the Home �� 316
9.12.3 Treating Asthma in the Office�� 317
9.12.4 Cardiopulmonary Resuscitation (CPR)�� 318
9.13 Anaphylaxis: Type 1 Allergy�� 318
9.13.1 Definition�� 318
9.13.2 Causes �� 319
9.13.3 Risk Factors for Anaphylaxis�� 321
9.13.4 Symptoms �� 321
9.13.5 Differential Diagnosis of Anaphylaxis�� 322
9.13.6 Management of Anaphylaxis�� 322
9.13.7 Education for Anaphylaxis�� 323
Part II The Role of Education
10 An Integrated Approach to Asthma Management�� 335

10.2 Asthma Management: A General Approach �� 336
10.2.1 Steps Taken by Healthcare Provider �� 336
10.2.2 Approach to Management: Role of Educator �� 337
10.2.3 Educational Visits �� 337
10.3 Management of Problems by Age�� 345
10.3.1 Less than 1 Year�� 345
10.3.2 From 1 to 5 Years�� 346
10.3.3 From 5 to 12 Years�� 346
10.3.4 From 12 to 25 Years�� 346
10.3.5 From 25 to 35 Years�� 348
10.3.6 From 35 to 60 Years�� 348
10.3.7 Over 60 Years�� 348
10.4 Home Monitoring�� 348
10.4.1 The Peak Flow Meter�� 348
10.4.2 Calculating Diurnal Variability: Other Methods�� 351
10.4.3 New Personal Best Readings�� 352
10.4.4 Checking PEF Technique�� 352
10.4.5 The Peak Flow Diary�� 353
10.4.6 Observing Symptoms and Using the Diary�� 354
10.4.7 The Asthma Action Plan �� 355
10.5 Severe, Acute, and Chronic Asthma�� 362
10.6 Potentially Fatal Asthma �� 363
Contents xv
11 Adherence �� 369

11.2 Healthcare Providers and Self-Management�� 371
11.3 Adherence: Common Issues �� 372
11.3.1 Asthma as a Chronic Condition�� 373
11.3.2 Medication Regimens �� 374
11.3.3 Avoidance of Triggers�� 375
11.3.4 Recognition of Deterioration�� 375
11.3.5 Reaction to Emergency Situations�� 375
11.3.6 Impact of Asthma�� 376
11.3.7 Coping Strategies�� 378
11.3.8 Psychosocial Factors�� 381
11.4 Adherence �� 385
11.4.1 Definition�� 385
11.4.2 Physician and Healthcare Provider
Adherence to Guidelines�� 386
11.4.3 Nonadherence �� 388
11.4.4 Patterns of Nonadherence �� 389
11.4.5 Identifying Nonadherence�� 390
11.4.6 The Team Approach�� 391
11.5 General Approach to Adherence �� 392
11.5.1 Strategies for Chronic Illness�� 393
11.5.2 Anticipatory Guidance�� 394
11.5.3 Skills Required by the Educator �� 397
11.6 Specific Aids to Adherence �� 398
11.6.1 Self-Management of Asthma�� 401
11.6.2 Health Education�� 406
11.7 Cultural and Religious Differences�� 407
11.8 Suggested Reading�� 414
12 Complementary and Alternative Medicine in Asthma �� 421
12.2 Specific Types of Care�� 426
12.2.1 Relaxation �� 427
12.2.2 Meditation �� 427
12.2.3 Yoga�� 427
12.2.4 Biofeedback�� 427
12.2.5 Breathing Exercises�� 428
12.2.6 Hypnosis �� 428
12.2.7 Imagery �� 428
12.2.8 Therapeutic Touch�� 428
12.2.9 Religion�� 429
12.3 Professions�� 429
12.3.1 Osteopathy�� 429
12.3.2 Chiropractic�� 429
12.3.3 Acupuncture�� 431
xvi Contents
12.3.4 Homeopathy�� 432

12.3.5 Massage Therapy�� 433
12.3.6 Naturopathy�� 433
12.4 Self-Help CAM�� 434
12.4.1 Herbs �� 434
12.4.2 Nutrition and Nutritional Supplements�� 436
12.4.3 Exercise as Treatment �� 437
12.4.4 Electromagnetic Treatment �� 438
12.4.5 Aromatherapy �� 438
12.4.6 Reflexology �� 438
12.5 Approach of the Educator �� 438
13 Frequently Asked Questions �� 445
13.2 Asthma: Symptoms and Control�� 446
13.3 Triggers �� 449
13.4 Fatal Asthma �� 453
13.5 Exercise and Asthma�� 453
13.6 Medications�� 454
13.7 Testing and Devices�� 458
13.8 Spacers�� 459
13.9 The Peak Flow Meter�� 460
13.10 Allergies�� 461
13.11 School and Camp�� 463
13.12 Pregnancy�� 464
13.13 Travel�� 465
13.14 Coping�� 466
13.15 Immunizations�� 470
13.16 Other Questions�� 471
Part III The Effective Asthma Educator
14 Learning: Theories and Principles �� 477

14.1.1 How Is Learning Achieved?�� 479
14.2 Learning and Teaching Definitions �� 479
14.2.1 Learning�� 479
14.2.2 Teaching�� 479
14.3 The Learning Process�� 479
14.4 Theories of Learning�� 480
14.4.1 Behaviorism�� 480
14.4.2 Gestalt or the Cognitive Theory of Learning�� 483
14.4.3 The Humanistic Theory�� 486
14.4.4 Information Processing �� 488
14.5 Online Learning: Some Considerations�� 491
14.6 Personality Development�� 493
Contents xvii
14.6.1 Infancy: Trust Versus Mistrust�� 493

14.6.2 Early Childhood: Autonomy Versus Shame
and Doubt�� 493
14.6.3 Middle Childhood: Initiative Versus Guilt�� 494
14.6.4 Elementary School Age: Accomplishment
Versus Inferiority�� 494
14.6.5 Adolescence: Identity Versus Confusion�� 494
14.6.6 Young Adulthood: Intimacy Versus Isolation �� 494
14.6.7 Adulthood: Generativity Versus Stagnation�� 494
14.6.8 Old Age: Integrity Versus Despair�� 494
14.6.9 Application of Theories to Asthma Education�� 495
14.7 Age-Related Learning�� 496
14.7.1 Learning Styles �� 496
14.7.2 Children�� 497
14.7.3 Adolescents �� 497
14.7.4 Adults�� 498
14.7.5 Older Adults�� 499
14.7.6 Implication of Learning Styles�� 499
14.7.7 Types of Learning �� 502
14.8 Barriers to Learning�� 503
14.8.1 Environment�� 503
14.8.2 Physical Factors�� 504
14.8.3 Individual Factors �� 504
14.8.4 Sociological and Emotional Factors �� 506
14.9 Principles of Learning�� 508
15 Teaching the Person with Asthma�� 515
15.2 Teaching Approaches for Different Audiences �� 517
15.2.1 Parents�� 517
15.2.2 Children�� 520
15.2.3 Adolescents �� 522
15.2.4 Adults�� 525
15.2.5 Low-Literacy Individuals�� 527
15.2.6 The Older Adult�� 528
15.2.7 Response to Education�� 530
15.2.8 Cultural Competency�� 530
15.2.9 Mobile Applications for Asthma�� 532
15.3 Teaching Methods�� 534
15.3.1 The Individual�� 535
15.3.2 The Small Group�� 536
15.3.3 The Large Group�� 537
15.4 The Process of Education�� 538
15.4.1 The Cognitive Domain�� 539
15.4.2 The Affective Domain�� 540
15.4.3 The Psychomotor Domain�� 543
xviii Contents
15.5 Planning for Teaching �� 544

15.5.1 Assessment�� 544
15.5.2 Planning�� 546
15.5.3 Planning for the Affective Domain �� 546
15.5.4 Planning for the Cognitive Domain�� 547
15.5.5 Planning for the Psychomotor Domain�� 547
15.5.6 Implementation �� 548
15.5.7 Evaluation �� 548
15.5.8 Sample Teaching Plans �� 550
15.6 The Role of the Educator�� 551
15.6.1 Principles of Communication in a Consultation �� 551
15.6.2 Setting the Climate for Teaching�� 552
15.6.3 Ways of Teaching That Can Cause Problems �� 554
15.7 Teaching Strategies �� 556
15.8 The Team Approach to Teaching�� 562
16 Clinic Management and Evaluation�� 569
16.2 Running an Asthma Clinic�� 571
16.2.1 Facilities�� 572
16.2.2 Time�� 572
16.2.3 Equipment and Materials�� 572
16.2.4 Telemedicine �� 576
16.2.5 Resources�� 577
16.2.6 Evaluation of Teaching Materials �� 579
16.2.7 Education Programs�� 580
16.2.8 Planning�� 580
16.2.9 Costs�� 581
16.2.10 Data Collection �� 581
16.2.11 Standards�� 581
16.3 Teaching in the Home �� 584
16.3.1 Assessing the Environment�� 584
16.3.2 The Home Teaching Kit�� 586
16.4 The School Environment�� 587
16.4.1 Classroom Assessment�� 587
16.4.2 Within the School�� 588
16.4.3 Outside the School�� 588
16.4.4 School Policies�� 589
16.4.5 Physical Education�� 590
16.4.6 General Education for School Staff�� 590
16.5 Evaluation of Education Programs �� 591
16.5.1 Designing an Evaluation Program�� 592
16.5.2 Establishing Standards�� 595
16.5.3 Data Collection �� 596
16.5.4 Data Analysis and Evaluation �� 596
16.5.5 Review�� 597
Contents xix
16.5.6 Confidentiality�� 599

16.6 Self-Evaluation�� 599
16.6.1 Using the Self-Evaluation Checklists �� 600
16.7 Self-Evaluation Checklists�� 601
16.7.1 Checklist 2�� 603
Appendix 16.1�� 605
Reading Material for Patients�� 605
Internet Addresses�� 605
General Interest�� 606
For Asthma Educators (Not for Patients)�� 606
Suggested Reading for Asthma Educators�� 606
Part IV Case Studies
17 Case Studies�� 613

17.2 Instructions for Case Studies 1 to 14�� 614
17.3 Additional Case Studies�� 614
17.4 Case Study 1 �� 614
17.5 Case Study 2 �� 614
17.5.1 Response to Case Study 1 �� 615
17.6 Case Study 3 �� 615
17.7 Case Study 4 �� 615
17.8 Case Study 5 �� 616
17.9 Case Study 6 �� 617
17.10 Case Study 7 �� 619
17.11 Case Study 8 �� 620
17.12 Case Study 9 �� 621
17.13 Case Study 10 �� 622
17.14 Case Study 11 �� 623
17.15 Case Study 12 �� 623
17.16 Case Study 13 �� 624
17.17 Case Study 14 �� 625
Glossary�� 627
Index�� 635
Abbreviations
AAP Asthma Action Plan

AARC American Association for Respiratory Care
AAT Alpha 1-anti-trypsin
ABPA Allergic Bronchopulmonary Aspergillosis
ACCI Asthma Control and Communication Instrument
ACE Angiotensin Converting Enzyme
ACO Asthma-COPD Overlap
ACQ Asthma Control Questionnaire
ACT Asthma Control Test
ACTH Adrenocorticotrophic Hormone
AE-C Certified Asthma Educator
ALB Asian Ladybug
AMP Adenosine 5’ Monophosphate
APGAR Activities, Persistence; triGGers, Asthma medications, Response
to therapy
AR Allergic Rhinitis
ARIA Allergic Rhinitis Impact on Asthma
ASA Acetylsalicylic Acid
ATAQ Asthma Therapy Assessment Questionnaire
ATS American Thoracic Society
BAL Bronchoalveolar Lavage
BHR Bronchial Hyper-Reactivity/Hyper-Responsiveness
BMI Body Mass Index
BT Bronchial Thermoplasty
CAM Complementary and Alternative Medicine
CC Conventional Cigarette
CDC Centers for Disease Control and Prevention (USA)
CNS Central Nervous System
CO Carbon Monoxide
CO2 Carbon Dioxide
CO2e Carbon Dioxide Equivalents
COLD Chronic Obstructive Lung Disease, also called COPD
COPD Chronic Obstructive Pulmonary Disease, also known as COLD
CORE Cough, Obstructive Sleep Apnea, Rhinosinusitis and Esophageal
Reflux.
CPR Cardio Pulmonary Resuscitation
DPI Dry Powder Inhaler
xxi
xxii Abbreviations
DTCA Direct to Consumer Advertising

EBC Exhaled breath condensate
EC Electronic Cigarette, E-cigarette
ED Emergency Department
EIA Exercise Induced Asthma
EMR Electronic Medical Records
EPR-3 Expert Panel Report 3 (by the National Asthma Education and
Prevention Program)
ERV Expiratory Reserve Volume
ETS Environmental Tobacco Smoke
EVALI E-cigarette Vaping Use Associated Lung Injury
FDA Food and Drug Administration (U.S.)
FeNO Fraction of Exhaled Nitric Oxide
FEV1 Forced Expiratory Volume in One Second
FOT Forced Oscillation Technique
FRC Functional Residual Capacity
FVC Forced Vital capacity
GERD Gastroesophageal Reflux Disease
GINA Global Initiative for Asthma
GRAS Generally Regarded as Safe
HCP Health Care Professional
HDM House Dust Mites
He Helium
HEPA High Efficiency Particulate Air
HFA Hydrofluoroalkane
HIPPA Health Insurance Portability and Accountability Act
HMO Heath Maintenance Organization
HPA Hypothalamic Pituitary Adrenal (axis)
HRCT High Resolution C T
HRQoL Health-Related Quality of Life
IC Inspiratory Capacity
ICS Inhaled Corticosteroids
ICU Intensive Care Unit
IgE Immunoglobulin E
IOC International Olympic Committee
IRV Inspiratory Reserve Volume
JCAHO Joint Commission on Accreditation of Healthcare Organizations
LABA Long-Acting Beta Agonists
LAMA Long-Acting Muscarinic Agent
LTRA Leukotriene Receptor Antagonist
MAO Monoamine Oxidase Inhibitors
MDI Metered-Dose Inhaler
N Nitrogen
NAEPP National Asthma Education and Prevention Program
NCCLS National Committee for Clinical Laboratory Standards
NCES National Center for Educational Statistics
NCICAS National Co-operative Inner City Asthma Study
NHANES National Health and Nutrition Examination Survey III
Abbreviations xxiii
NHLBI National Heart, Lung and Blood Institute

NIH National Institutes of Health
NP Neuropsychiatric
NRT Nicotine Replacement Therapy
NSAID Non-Steroid Anti-Inflammatory Drug
O2 Oxygen
OCL Online Collaborative Learning
OCS Oral Corticosteroids
OLD Occupational Lung Disease
OR Odds Ratio
OSA Obstructive Sleep Apnea
OTC Over-the-Counter
PaCO2 Partial Pressure of Carbon Dioxide
PCC Patient-Centered Care (also known as PFC)
PDR Physicians’ Desk Reference
PEF Peak Expiratory Flow
PEFM Peak Expiratory Flow Meter
PEFR Peak Expiratory Flow Reading
PFA Potentially Fatal Asthma
PFC Patient-Focused Care
PFM Peak Flow Meter
PPD p-Phenylenediamine
PSG Polysomnography
QALY Quality-Adjusted Life Years
QOL Quality of life
RAD Reactive Airway Disease
RAW Airway Resistance
RCT Randomized Controlled Trials
REM Rapid Eye Movement
RS Rhinosinusitis
RSV Respiratory Syncytial Virus
RTI Respiratory Tract Infection
RV Residual Volume
SABA Short-Acting Beta Agonists
SCIT Subcutaneous Immunotherapy
SIDS Sudden Infant Death Syndrome
SLIT Sublingual Immunotherapy
SPD Serious Psychological Distress
SPO2 Oxygen Saturation
TGV Thoracic Gas Volume
TLC Total Lung Capacity
TRACK Test for Respiratory and Asthma Control in Kids
TSP Tri-sodium Phosphate
TV Tidal Volume
UAO Upper Airway Obstruction
UNDW Ultrasonically Nebulized Distilled Water
UNESCO United Nations Educational Scientific and Cultural Organization
URI Upper Respiratory Infection
xxiv Abbreviations
VC Vital Capacity
VCD Vocal Cord Dysfunction
VOC Volatile Organic Compounds
WHO World Health Organization
Part I
Asthma: The Fundamentals
Asthma and Asthma Education:
The Background
1
Contents
1.1 Introduction 4
1.2 What Is Asthma? 5
1.2.1 Symptoms 5
1.2.2 Definitions 7
1.3 Significance of Asthma 8
1.3.1 Overview 8
1.3.2 Morbidity 9
1.3.3 Mortality 11
1.3.4 Costs 12
1.4 Etiology of Asthma 15
1.4.1 Allergy and Asthma 15
1.5 Genetics and Environment 16
1.5.1 Phenotype and Genotype Correlation 16
1.5.2 Environmental Issues 17
1.6 Approaches to Asthma 20
1.6.1 Guidelines 20
1.6.2 NHLBI Guidelines 20
1.6.3 Pediatric Guidelines 23
1.6.4 COVID-19 and Asthma 24
1.6.5 Organization of Care 25
1.6.5.1 General Approach of Health Systems 25
1.6.5.2 Healthcare Professionals 26
1.6.5.3 Personal Responsibility 27
1.7 Education of Persons with Asthma 27
1.7.1 The Issues 27
1.7.2 Role of the Asthma Educator 29
1.7.3 Skills of the Asthma Educator 30
1.7.4 Essential Qualities of the Educator 31
References 33
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 3

I. Mitchell, G. Govias, Asthma Education, https://doi.org/10.1007/978-3-030-77896-5_1
4 1 Asthma and Asthma Education: The Background
1.1 Introduction
Key Points
• Asthma is a significant and common This chapter is intended to serve as an introduc-
condition. tion to the world of asthma education—to the
• Definitions and symptoms are provided, various facets of knowledge and skills needed by
together with an impact on health, the successful asthma educator. It hence provides
including costs and the fact that it may only brief overviews of the many components
cause premature death. that make up asthma education, and its purpose is
• Asthma is closely related to allergy. to paint a “big picture” to help place various
–– Allergy and asthma have common asthma- and education-related topics in
genetic and environmental factors. perspective.
–– The relevance of phenotype-
genotype correlations are described.
Points to Ponder
–– Factors relevant to the less common
but important non-allergic asthma If physicians, or healthcare providers and
are described. others, assume that wheeze is essential for
• Guidelines are important to all the diagnosis of asthma, then the diagnosis
approaches to asthma. will often be missed.
–– These require organization of care
and system-wide measures.
–– Those with asthma have a personal
responsibility in their care. While other chapters in the book each address
• Health professionals—and especially a single topic in detail and may be read in part or
the Asthma Educator—have a specific in whole or in the order that meets a specific
and important role in the education of need, this chapter should be read first, in its
people with asthma. entirety.
–– The skills and essential qualities of The effective asthma educator requires a good
the asthma educator are described in understanding both of asthma in all its aspects
detail. and of the teaching process. Teaching is a form of
empowerment—in this case, empowerment of
people with asthma. The asthma educator must
know how to effectively transfer knowledge
Chapter Objectives about asthma and its treatment methods and man-
agement techniques to the person with asthma,
After reading this chapter, you should be thereby empowering and helping him or her to
able to: effectively self-manage his or her asthma.
The aim of the asthma educator is to help peo-
1. List the warning signs and symptoms of ple with asthma stay well. When writing about
asthma. these people, we are unsure what term to use.
2. Explain the definitions of asthma. When they get sick, they are correctly designated
3. Describe the current guidelines for
as patients. But much of the time, perhaps most of
asthma. the time, they are well and the word “patient”
4. Discuss the organization of care for a seems inappropriate. This discussion pervades all
person with asthma. aspects of healthcare, with alternative language of
5. Explain the importance of education
“client” or “consumer” suggested [1, 2]. We
and the role of educators in asthma understand this discussion, but want the empow-
management. ered person with asthma to enjoy a good and full
life. We will talk about asthma and people with
asthma throughout this book, using other designa- therefore the logical starting point for this
tions when appropriate. However, we will never chapter.
use “asthmatic,” for it is a term that defines an Some people with asthma have symptoms
individual solely by a medical problem and thus throughout their lives and others at one life stage
removes individuality and perhaps humanity. only and still others have symptoms in more than
While this book contains the information one life stage, but with long periods of remission.
needed to prepare for the Asthma Educator’s For those in the first category, the symptoms do
Certification (AE-C) examination, it goes much not necessarily remain the same at all life stages.
further: it is intended as an ongoing reference, and Hence, a broad division of asthma into “pediat-
it presents supplementary information and discus- ric” and “adult” is insufficient for the knowledge-
sions that can enrich the educator’s practice. It able educator, who needs to understand the
will also, hopefully, show that the goal of effec- special characteristics of the disease at different
tive teaching is to present information in such a ages. For example, the symptoms of an infant are
way that that information is easily remembered, likely to be different from those of a 9-year-old or
that its value is understood, and that it is then used of a teenager, although all three are considered to
(by people with asthma) for personal benefit. have “pediatric” asthma. Similarly, the predomi-
This chapter will also indicate the directions nant symptoms of adults aged, say, 25, 50, or 70
that our collective understanding of asthma will may differ considerably.
take. These will be speculative to some extent The major common symptoms of asthma are:
and based on the authors’ extrapolation and inter-
pretation of current knowledge. Such information • Cough
is clearly not needed for asthma educators to be • Wheeze
successful in their work, but it will enhance their • Shortness of breath
knowledge of various trends and in turn will • Chest pain or chest tightness
enrich the understanding they bring to their edu-
cation of those with asthma. Variations and differences in these symptoms
This book is written as the COVID-19 pan- occur at different ages; they will be discussed in
demic rages. Healthcare practitioners have all later chapters.
had to change their practice and learn new skills. Some people will complain of wheeze, but
One specific skill that is likely to persist when the this is unusual as a presenting complaint and
pandemic is over is the ability to help those with indeed, most persons with asthma will report
asthma using virtual techniques. At the least, this cough or shortness of breath. Shortness of breath
might involve using a phone with both the educa- is thus the most common complaint and the one
tor and the person with asthma looking at a web- which interferes most with the quality of life for
site. But much more elaborate online educational individuals with asthma. It is not usually con-
programs are currently available and will be stant, unless the asthma is particularly severe, but
developed even further. There will not be a return occurs in episodes. The shortness of breath may
to “life as before.” start suddenly during the night, with attendant
This, in brief, is the purpose of the book. Now fear and extreme anxiety, or it may come after
let us proceed and define its subject. exercise or exposure to triggers. In some
instances, chronic breathlessness may develop,
but without the feeling of distress. While the lack
1.2 What Is Asthma? of distress may reduce stress, it simultaneously
increases the danger; there may be no realization
1.2.1 Symptoms of the degree of deterioration that exists.
Cough is the most common symptom. It is
Symptoms are “what is felt.” They are the main most often dry and irritating and generally worse
impetus in seeking healthcare advice. They are at night, although occasionally sputum is pro-
duced. Cough may follow exercise or exposure to deterioration in asthma, such as with a common
allergenic triggers. In children, cough may be the cold. It may occur after a cough, but can also
only symptom reported by parents, and this occur without a cough. Vomiting usually subsides
cough is often confused with croup. In adults, as the asthma improves.
cough is often confused with pneumonia. Wheeze People with asthma may also present with
is found at the same time that a person presents other symptoms that are caused by or due to
with cough or shortness of breath. It may be asthma. These include fatigue, reduced activity,
heard by the person but may also be an objective and disturbed sleep. Other signs and symptoms
finding on physical examination by a healthcare are listed in Table 1.1. It is important to remem-
professional. Louder wheezes can be heard by ber that these will vary from person to person.
bystanders. Some young children may have cough as their
While the presence of wheeze strongly sug- only symptom, especially at night or during the
gests asthma, its absence does not mean that early hours of the morning, while others may
asthma itself is absent. And the contrary is also not cough at all. However, all persons with the
true; asthma might be the most common cause of disease—and more particularly the parents of
wheeze, but many other conditions may cause it. young children with asthma—should be made
Aaron et al. [3] suggest up to a third of those aware both of the signs and the symptoms, with
diagnosed with asthma may turn out to have particular emphasis on the danger signals of
some other condition. Of those who do have asthma.
asthma, many never wheeze, or wheeze so occa- When asked, most people will usually describe
sionally that this is never heard by a healthcare only their symptoms to a healthcare provider.
provider during a physical examination. They However, they will also have their own personal
may have cough, particularly at night. In severe ideas and anxieties about their asthma and the
acute asthma, wheeze may be absent since there significance of their symptoms. Healthcare pro-
is insufficient airflow to produce the noise. This viders must pay attention to these anxieties when
so-called silent chest is a marker of severity and they ask for a description of the symptoms, as
requires urgent action. they will often describe the effect asthma has on
If it is assumed that wheeze is essential for the their quality of life. For example, they may worry
diagnosis of asthma, then the asthma will often about the regular use of expensive medications,
be missed, and the diagnosis will be incorrect. interference with exercise and with sleep, prob-
Other symptoms do exist. For instance, chest
tightness is very common and will disappear with
treatment. Others will complain of chest pain, Table 1.1 Signs and symptoms of asthma
and care must be taken to distinguish this from Warning signs Danger signs
other causes of chest pain, such as problems with Suddenly becomes Skin retracted at base of throat
the heart or with the chest wall itself–in other quiet or withdrawn and between ribs
Looks distressed Nostrils flared
words, strain involving the muscles of the rib Coughs Breathing rate is above normal
cage. Chest pain is a symptom that seems to be Wheezes (adults: 25 or more; children:
particularly common in adolescents and is per- Feels breathless 30 or more)
haps related to changes in the configuration of the Coughs at night, after Blue tinge on lips, and nail
exercise or in cold air beds
chest wall that occur with growth. Has tightness or pain Cannot say a complete
Vomiting, by itself, is not a symptom of in chest sentence in one breath
asthma, but at least one-third of children with Takes longer to breathe Rapid pulse (adults: 110 or
asthma will vomit at some time. Vomiting is so out than breathe in more; children: 120 or more)
Vomits Peak flow readings 33% to
common that there is an old belief that inducing 50% below normal levels
vomiting will lead to improvement in the asthma. Says or feels that medication
While this is incorrect, the vomiting remains is ineffective
unexplained. It is associated with coughing and Pulsus paradoxus >10mmHg
lems with relationships, embarrassment with iarity with the disease, an easy definition that fits
noisy breathing, and so on. Surveys [4–7] show all situations remains elusive.
that persons with asthma have a high incidence of Educators should be familiar with the defini-
symptoms and disturbance in their lives, affect- tion of asthma by the National Institute of Health
ing mobility, school attendance, work, leisure, (NIH) Expert Panel Report on Guidelines for the
sleep, and medication usage and causing avoid- Diagnosis and Management of Asthma. It is com-
ance of everyday activities such as sports, social plex and comprehensive, and states that:
gatherings, and even mild exercise. Asthma is a chronic inflammatory disorder of the
The healthcare provider must guard against airways in which many cells and cellular elements
superficial inquiry about symptoms, even if the play a role, in particular mast cells, eosinophils, T
person being examined states that they live nor- lymphocytes, macrophages, neutrophils and epi-
thelial cells. In susceptible individuals this inflam-
mal lives. Their definition of “normal” may be far mation causes recurrent episodes of wheezing,
removed from the normal lives led by healthy breathlessness and coughing, particularly in the
persons without asthma and be based on the night or early morning. These episodes are usually
restrictions and adjustments they have already associated with widespread but variable airflow
obstruction that is reversible either spontaneously
incorporated into their lives. This redefinition or with treatment. The inflammation also causes an
may be a form of coping mechanism that enables associated increase in the bronchial hyperrespon-
them to emphasize the positive aspects of their siveness to a variety of stimuli. Reversibility of air-
lives, thus permitting them to develop and extend flow limitation may be incomplete in some patients
with asthma [11].
their current coping skills and avoid dealing with
the problems of chronic illness [8, 9]. Similarly, Despite the comprehensive nature of this defi-
when they talk about “exercise,” it is important to nition, other special use definitions also exist.
understand what they mean by the term. For Some are created for research purposes, others
many individuals, exercise is a special activity for clinical practice, and still others for adminis-
carried out in a gymnasium, on a sports field, or trative purposes. It is worth examining these
at a fitness club. Everyday activities such as walk- other definitions, since each provides a different
ing, using stairs, vacuuming, and housework are viewpoint and different information about the
often not considered exercise. disease.
Hence, when asking about asthma symptoms,
exercise, or the response to treatment, specific
Points to Ponder
questions must be included about daily routine or
everyday activities. In the case of children, paren- A definition of asthma should:
tal perception of asthma severity in a child may
differ from objective measures of severity, but • Allow for the recognition of asthma
both must be considered when evaluating the • Enable meaningful tests to be used in
child’s ability to function [10]. Individuals with the diagnosis of asthma
asthma may overestimate or even underestimate • Be of use in assessing severity
the severity of their symptoms. And older suffer-
ers may have greater limitations and symptoms
that are negated by familiarization and the devel-
opment of coping strategies [4]. The conventional medical definition, which
has been used for many years, is that asthma is
“reversible airways obstruction.” This confirms
1.2.2 Definitions that asthma is in the airways, is concerned with
airflow, and is variable. In other words, asthma
Asthma has literally been around for a very long may improve or deteriorate, sometimes over a
time! It was described thousands of years ago in surprisingly short time. To use this particular
the time of Hippocrates. Despite this long famil- definition, there needs to be a measurement of
airflow that can then give an indication of the implies that it will continue for many months or
degree of obstruction in the airways. years, in some perhaps for a lifetime, while in
There are many different ways of applying the others it may come and go over surprisingly long
definition, such as by history, by measurement, or periods. It is not a progressive condition that pro-
by pathology [12]. Professionals and scientists ceeds over time from mild to severe; rather, its
view and describe asthma in terms quite different clinical course is one of exacerbations and remis-
from those used by those who actually have sions [14]. Individuals with asthma may have it at
asthma. The Global Initiative for Asthma (GINA) one stage in their lives; it may then remit, only to
[13] defines asthma as: recur many years later. It is common for adults to
a chronic inflammatory disorder of the airways in present with asthma for what appears to be the
which many cells and cellular elements play a role. first time, only to discover or remember that they
The chronic inflammation causes an associated had had it in childhood. Thus, the chronic nature
increase in airway hyperresponsiveness that leads of asthma is one reason why education and indi-
to recurrent episodes of wheezing, breathlessness,
chest tightness, and coughing, particularly at night vidual involvement are extremely important [15].
or in the early morning. These episodes are usually Asthma is the second most common major
associated with widespread but variable airflow chronic disease found in Americans, the most
obstruction that is often reversible either sponta- common being dental decay. It was one of the 27
neously or with treatment.
focus areas defined by the US Department of
Both these definitions—by NIH and GINA— Health in Healthy People 2020 [16] through
stress the fact that asthma is a chronic inflamma- which improvements to the health of the nation
tory disorder of the airways, with the emphasis were monitored and for which objectives were
being on both the chronicity and its inflammatory defined. It continues to be a focus area in Healthy
nature. These are two very important aspects, People 2030 [17].
both of which must be understood by the health- Another very common chronic disease is rhi-
care provider and the individual with asthma in nitis. In most people, it can have less of an impact
order to manage the disease. The “reversibility” on quality of life than asthma. This is not invari-
component in the definition is essential for the ably true; for example, chronic upper airway
diagnosis of asthma. obstruction may lead to obstructive sleep apnea.
Despite difficulties in reaching agreement on Thus, it is easy to see the toll taken by upper and
a precise definition of asthma, the presence of lower respiratory diseases together. While its
asthma is recognized by most individuals and exact incidence is difficult to obtain, asthma
healthcare providers. The definition exists to affects about 1 in 13 Americans (at least 7.8% of
allow the recognition of the asthma, to enable adults, and 7.5% of children) [18]. An estimated
meaningful tests to be used in its diagnosis, and 42.7 million Americans have asthma [19]. As
for use in assessing severity. there may be more than one individual in a family
with the disease, perhaps one-quarter to one-third
of all families are affected by asthma at one time
1.3 Significance of Asthma or another.
As mentioned earlier, the severity of asthma
1.3.1 Overview varies considerably, both between individuals
and in any one individual at different ages. The
In dealing with definitions of asthma and its range of severity is wide. At one extreme, for
assessment, there is considerable concentration example, are persons with one or two episodes of
on the acute situation, with widespread use of wheezing that follow a very specific exposure,
words such as “episode,” “exacerbation,” or such as exercise in combination with a cold, and
“attack.” While the medical conditions described who have no symptoms at any other time. At the
by these words all occur, this should not obscure other extreme are persons who have severe daily
the fact that asthma is a chronic condition, which wheezing which does not fully respond even to
major environmental change and medication While asthma affects millions of Americans, it
therapy. has a very high impact on specific racial and eth-
However, defining what is severe asthma is nic groups. Race and ethnicity refer to different
complex. FitzGerald et al. [20] point out the personal qualities, but are often considered
importance of distinguishing uncontrolled and together, and the language to refer to them is still
severe asthma. Taking measures to improve health evolving. “Hispanic” is less used, having been
in these variants requires very different approaches. replaced by “Latino” and “Latina,” words in turn
Uncontrolled asthma might be due to inadequate superseded by “Latinx.” “African-American” and
asthma management, whereas severe asthma may “black” American may mean different things, but
already have optimal management, usually with are often used interchangeably. It is not clear
high-dose inhaled corticosteroids plus a second what is meant by the descriptor “white.” The con-
controller and/or systemic corticosteroids. These fusion is not surprising, as stereotyping the enor-
latter individuals should be considered for one of mous diversity of human appearance and ancestry
the new biologics [21]. In both cases, it is assumed is an impossible task even as smaller subgroups
a full diagnostic workup has been performed and are formed. The 2020 election of Senator Kamala
environmental exposures have been identified and Harris as Vice-President of the USA encapsulates
minimized prior to determining whether the much of the discussion. Is she African-American?
asthma is severe and/or uncontrolled. Black? Asian? Isn’t she all of these?! In general,
Asthma has an impact not only on the indi- when we cite studies, the language used will be
viduals concerned but also on their families, the that of the author, even if it feels limiting.
healthcare system, healthcare professionals, hos- In addition, race and ethnicity may gain rele-
pital usage, and medication costs. Performance at vance in large because of socioeconomic factors.
work and at school also suffers. These are the so-called social determinants of
health, the many background factors in our per-
sonal lives, our social connections, our economic
1.3.2 Morbidity status, and our home and work environments,
that are relevant to our health. There is a growing
Morbidity, briefly, is the incidence of the condition recognition of the importance of the social deter-
“asthma.” It can be extended to include the lack of minants of health; medical care alone, even of the
wellness, all the effects of illness, and the conse- highest quality, is not enough to ensure good
quent reduction in quality of life of the person with health.
asthma. The World Health Organization (WHO) For example, inner-city African-American,
defines health as a state “of complete physical, Hispanic, and Puerto Rican communities have
mental and social well-being and not merely the high rates of asthma. Puerto Ricans have the
absence of disease or infirmity.” The educator has highest rates of asthma in the USA. Overall,
an important role in helping those with asthma racial and ethnic minority populations have
achieve the highest level of well-being. higher rates of asthma and visit emergency
Many individuals with asthma do not enjoy department (ED) and physicians’ offices more
good health in the fullest sense of the term. Many often for treatment than do whites. Among chil-
children, and many adults, accept a surprising dren, more non-Hispanic black children have
degree of correctable ill health. This includes tol- asthma compared with Hispanic and non-Hispan-
erating disturbed sleep, avoiding sports, and tak- ics. Black Americans are more likely to be hospi-
ing time off from work or school for preventable talized and placed in intensive care for asthma
illnesses. Both the asthma educator and the than whites. They are also two to three times
healthcare provider must remember that persons more likely to die from asthma than any other
with asthma often accept ill health as a “normal group [18, 22–27].
state” and must take extra care to determine the Factors such as poverty, substandard hous-
effects of the disease on those they advise. ing, increased exposure to allergens, lack of
education, inability to follow prescribed regi- A combination of the following contributes to

men, and limited access to continuous medical the increased risk of asthma morbidity [39]:
care all contribute to elevated morbidity,
increased severity, uncontrolled asthma, and • Poor problem-solving skills
even death. This ethnic or racial variation in • Multiple caregivers (many of whom are
health status is the result both of exposure or extended family members)
vulnerability to environmental, behavioral, and • Adjustment problems, both behavioral and
psychosocial factors and also due to a lack of emotional
resources [28–32]. Most of these may be con- • The caregiver’s high level of stress in caring
sidered “downstream” effects, but these effects for a child with a chronic illness while coping
are shaped by “upstream” effects. Upstream with the burdens of poverty [40–42]
effects can only be changed by political actions,
such as addressing poverty and improving edu- Asthma also accounts for the greatest num-
cational standards. Even if these changes are ber of absences from school and is the cause of
made, they will not translate into immediate [34, 43]:
improvements in health. Hence, when profes-
sionals interact with someone with asthma, • Low self-image in some individuals
they will do their best to help in amelioration of • Poor school or work performance [44]
factors, such as reducing allergen exposure that • Disruption of family life [35]
if possible and successful will have an immedi-
ate impact on asthma. We hope all healthcare Absence from school due to asthma has a neg-
professionals, including asthma educators, ative impact on educational achievement and also
understand that many important factors are not later in life [43]. Thus, such absence may be a
under any degree of control of the person with marker of asthma severity and a consideration in
asthma or his or her family. treatment outcomes.
An understanding of the social determinants Children with asthma also have more dis-
of health helps to explain why morbidity is ele- turbed sleep; perform less well on tests of
vated in those who come from inner-city neigh- memory and concentration; and tend to have
borhoods. Increased severity of asthma is more psychological and behavioral problems
associated with greater feelings of stigmatiza- [41, 45, 46].
tion, more negative attitudes towards healthcare The more severe the symptoms, the greater the
providers, and reduced self-confidence in the psychiatric morbidity [33]. It seems from the evi-
ability to manage asthma [33]. dence that psychiatric morbidity is a consequence
Socioeconomic status, as one of the social of the severe asthma, rather than the reverse, but
determinants of health, is related to health out- this of course is difficult to prove absolutely.
comes [26, 33]. In low-income and black popula- Lack of sleep in children impinges on their cog-
tions, it is the major cause of medical emergencies, nitive abilities during the day and affects mood,
increased ED visits, and hospitalizations [25, 35]. behavior [47], and sense of well-being. This also
Females, low socioeconomic groups, and ethnic applies to caregivers and adults. At the same
minorities in particular have a poorer quality of time, some of the changes are very difficult to
life because of their asthma [4, 24, 36, 37]. quantify. For example, if children have inade-
Asthma morbidity is thus governed by the quate education because of disturbed sleep or
four major risk factors [38] of: poor morale, it may affect their career choices
and their lifestyle as adults. Limitations because
• Genetics of allergies or asthma may also affect the choice
• Environment of geographic area in which they can live.
• Socioeconomic status The use of quality-of-life (QOL) measures is
• Psychosocial determinants part of a general trend that supplements tradi-
tional medical outcomes with individual or with Hispanics they are three times more likely
family-centered outcomes. In asthma, these to die from asthma than whites. Why this is so
include sleep quality; ability to exercise; time lost has not been explained, though the incidence of
from work because of personal asthma or to look asthma among the African-American and
after children with asthma; career opportunities Hispanic population is much higher than among
missed or taken; and forced alterations in the the white.
home to change the environment. All have a Asthma mortality shows a high correlation
severe impact on the family’s quality of life, par- with race and low socioeconomic status [23, 25,
ticularly that of the caregivers [48–50]. 52]. It is surmised that because impoverished
Some items, such as time lost from work, may individuals lack access to continuous medical
also have a financial impact. There are other care, they neglect their illness until an acute exac-
monetary aspects that must be borne in mind erbation forces a visit to an ED [53]. The result is
when taking a comprehensive view of asthma, partial recovery before the next exacerbation.
such as the cost of medications, of environmental This unrelenting cycle can deplete the person’s
changes or modifications that may be needed to physical resources and increase the impact of the
living spaces, of additional cleaning or house- disease. Most deaths occur in those who have
keeping requirements, and so on. severe asthma and whose disease has been inad-
equately controlled over a long period [54, 55].
While some deaths are related to overwhelming
1.3.3 Mortality and sudden allergen exposure, this is not
common.
Deaths from asthma continue to occur, with the A number of detailed studies have been done
numbers varying over time. There have been on the cause of the deaths and the life circum-
well-documented epidemics of asthma deaths in stances of those who die [52, 54, 56–62]. Deaths
the USA, England, Australia, New Zealand, and have been associated with depression, denial of
many other countries. During these epidemics, the disease, anxiety, family conflicts, life crises,
the death rate has risen; after a period, it has and social isolation. Many deaths were found to
fallen, but never to zero. There has been (and is) be related to poor adherence and also to poor
much speculation on the cause of these epidem- physician understanding of the disease [63]. In
ics, and many new interventions are tried during short, they were preventable.
each epidemic. It is never clear whether the inter- As far as physicians are concerned, there was
ventions have led to improvement in the mortal- a failure of management [13] in that:
ity rate or whether the natural history of the
epidemics of asthma deaths tends towards spon- • Deterioration was often not recognized early
taneous improvement. enough, and clinical status was not adequately
Between 1960 and 1998, the prevalence of assessed.
asthma, and death rates for the disease, increased • Objective measures of severity were not used.
both nationally and regionally in the USA for all • The use of both inhaled and systemic cortico-
races, sexes, and ages [22]. In the year 2000, the steroids was not begun soon enough.
actual number of deaths fell to 4,497 (from an
earlier high of 5,400). According to a recent GINA states that underdiagnosis and inappro-
Center for Disease Control (CDC) report, the priate treatment were major factors contributing
death rate has continued to fall. Currently ten to asthma mortality and morbidity, although in
Americans die every day from asthma. 3,564 line with the comments above, some people have
people died from asthma in 2017 [51]. Adults die severe asthma that may continue with apparent
from asthma at five times the rate that children appropriate conventional treatment. Thus, under-
do. African-Americans had two to three times treatment and under-assessment can be fatal [54,
the death rate of whites [18, 23, 25]. Together 56, 59].
Individuals with asthma very often: ance or some form of government plan, but may
also be covered in part, sometimes wholly, by the
• Did not understand the use of medications and person with asthma.
preventive medication [59] Direct costs are determined using severity of
• Failed to recognize symptoms of deterioration asthma, adherence to prescribed medication regi-
[54] mens, the prevalence of the disease, and the
• Unable to follow advice on changes in their actual cost of healthcare in the country. Illiteracy
environment adds to these costs [65].
• Relied on symptomatic treatment such as a Indirect costs include days absent from school,
bronchodilator loss of work both in and outside the home, and
• Avoided preventative treatment with inhaled economic costs due to premature death. Indirect
corticosteroids or similar medications [58] costs are those borne in the main by the individ-
• Delayed getting medical help [58, 63, 64] ual or family. A significant percentage of the indi-
rect costs relate to children. This is a clear
It has been assumed until recently that the indication of the increasing prevalence of asthma
only hope for changing these factors is by educat- and the loss of resources, including time taken off
ing people about their symptoms and teaching from work to care for children in the home.
them how to manage the asthma through environ- By 2013, the estimate of the total annual cost
mental control and appropriate medication usage. of asthma stood at $88.4 billion. Published in the
Primary care-based interventions such as health Annals of the American Thoracic Society, the fig-
education can be effective in teaching individuals ures were considered low since they were based
with asthma how to achieve guided self- on an assumed prevalence of asthma of about
management of a troublesome condition that can 5%, though the National Health Survey put the
unnecessarily end in death. That statement prevalence at 8% [18]. Further, the costs were
remains true, but there is a subset of people with based only on individuals who were actually
severe asthma for whom one of the new biologi- receiving treatment through visits to providers,
cal agents is essential. Choosing which “bio- pharmacists, ED, or hospitals.
logic” is best for any one individual with asthma Assuming that the prevalence of asthma in all
will require detailed assessment of the biochemi- age and gender groups remains unchanged, in
cal and genetic features of that person’s 2019 Yaghoubi and colleagues [66] projected the
condition. excess costs of uncontrolled asthma for the next
20 years. Excess direct costs were estimated to be
$300.6 billion. With the addition of indirect costs,
1.3.4 Costs this raised the estimated excess total economic
costs to $963.5 billion. They also calculated that
Many attempts have been made to estimate the individuals with asthma would lose 14.46 million
cost of asthma, but it has proven difficult to get a quality-adjusted life years.
precise estimate. However, there is little doubt The projected excess cost estimates were
that this one condition accounts for a significant based only on uncontrolled asthma in adults.
percentage of overall healthcare spending. Pediatric costs were not included. As opposed to
US estimates are divided into direct and indi- the excess costs, the estimate of direct costs of
rect costs, with the major elements of direct costs uncontrolled asthma in adults over the same
being inpatient care, emergency visits, physician 20-year period was over $1.5 trillion. However,
services, and medications. Other direct costs if all the adults had well-controlled asthma, then
include nursing and ambulance services, devices, the saving in the USA would be an estimated
research, and community health education. In $300.6 billion in direct costs and a further
other words, what we refer to “direct costs” are $66.2 billion in indirect costs. See Tables 1.2
costs to the system that may be covered by insur- and 1.3.
While it is important to estimate dollar costs, spent on educating families. Lewis et al. [76]
they do not take into account loss of enjoyment of estimated a saving of $180 per child per year
life and other intangible costs, including the neg- subsequent to an education program. Bolton and
ative emotional impact; the fear, pain, unhappi- colleagues [77] found that for an educational
ness, and grief that result from a chronic illness investment of $85 per person, there was a reduc-
[67–71]; the loss of potential resulting from chil- tion in ED charges of $628 per person. In deal-
dren missing school due to the disease; and the ing with a group of adult women with a history
reduction in career choices available to adults. of repeated hospitalizations, Castro and others
A detailed knowledge of costs can be helpful found that an investment of $186 per person
when planning asthma-related services and when could result in a saving of both direct and indi-
devising measures to control costs. Costs can be rect costs of $6,462 per person, when the invest-
reduced by careful assessment that results in a ment involved appropriate education, support,
limited number of medications being prescribed, and counseling [78].
by the use of generic medications where avail- Nurmagambetov et al. [79] found the individ-
able, and, if necessary, by recourse to the indi- ual costs of asthma in 2013 to be
vidual’s insurance or prescription plans. And
obviously, fewer exacerbations translate into • $1,830 for prescription medications
much lower personal costs, to say nothing of a • $640 for office visits
better life and less suffering. • $529 for hospitalizations
Educators are the professionals who can • $176 for hospital outpatient visits
make the greatest impact on costs in both rou- • $105 for emergency room visits
tine care and emergencies. A person with asthma
who really understands his or her own condition Suh and colleagues [80] showed that a tar-
will need fewer admissions to hospital and geted asthma intervention program which actu-
fewer emergency visits, with resultant cost sav- ally increased individual asthma medication
ings [72–74]. A study by Clark et al. [75] costs by one dollar ($1) could reduce individual
showed that education did make a significant costs by
difference, with $11.22 being saved for every $1
• $149 for hospitalizations
• $16 for emergency room visits
Table 1.2 Projected excess costs of uncontrolled asthma
• $82 for physician visits
in adults
20-year Projected Excess Costs of Uncontrolled
Asthma ($m, rounded)
The numbers are in, and they show conclu-
Direct Costs Indirect Costs sively that effective asthma education can, on
Age (Years) Males Females Males Females average, save each person with asthma $725 in
15–30 40 44 99 188 direct and $1,239 in indirect costs and lower the
30–65 76 91 188 228 annual number of missed work days from 10.8 to
>65 20 30 19 25 2.6 [81].
Table 1.3 Projected excess costs of uncontrolled asthma according to age and gender
20-year Projected Excess Costs of Uncontrolled Asthma ($m, rounded)
Direct Costs Indirect Costs QALY Losta
Age Males Females Males Females Males Females
15–30 40 44 99 108 2,060 2,260
30–65 76 91 188 225 3,907 4,686
>65 20 30 19 25 1,022 1,526
Total 301 664 15,461
Quality-Adjusted Life Years Lost (‘000)
a
Another way to analyze costs is to consider oped to measure day-to-day function on a physi-
the costs of controlling asthma (through sched- cal, social, and emotional level. While these QOL
uled physician or healthcare provider visits, pro- scores have been developed for research purposes
phylactic medications, and education) against the and for studying new treatments, the concepts
costs of uncontrolled asthma (unscheduled behind them are more generally applicable and
healthcare provider visits, ED use, hospital are useful for educators to understand.
admissions, and so on). The costs of asthma have Some QOL principles are not specific for
been linked with lack of control over the disease, asthma and provide an overall profile of how a per-
with increasing costs directly related to the son is functioning in terms of health. There are also
increase in prevalence and severity. disease-specific QOL evaluation forms, as generic
The definition of what constitutes effective forms will not suit all purposes. Some are designed
therapy has undergone many changes. It is no to show differences between individuals and others
longer assumed that improvement in a laboratory to evaluate changes in an individual over time. The
test is synonymous with real-life improvement, scores are realistic rather than theoretical, and the
particularly from the point of view of the person rigorous method of development emphasizes their
with asthma. Much recent research has related relevance. See Fig. 1.1. Individuals are asked to
the clinical outcomes to what the person with estimate the issues important to them; and, as the
asthma actually feels, and tests have been devel- score is applied to many people, it is refined. One
Fig. 1.1 Some
references for quality- Wilson SR, Mulligan MJ, Ayala E, Chausow A, Huang Q, Knowles SB et al. A
of-life scores new measure to assess asthma's effect on quality of life from the patient's
perspective. J Allergy Clin Immunol. 2018 Mar; 141(3):1085-1095. doi:
10.1016/j.jaci.2017.02.047
Wilson SR, Rand CS, Cabana MD, Foggs MB, Halterman JS, Olson S, et al.
Asthma outcomes: quality of life. J Allergy Clin Immunol. 2012 Mar;129(3
Suppl):S88-123. doi: 10.1016/j.jaci.2011.12.988
Nishimura K, Hajiro T, Oga T, Tsukino M, Sato S, Ikeda A. A comparison of

two simple measures to evaluate the health status of asthmatics: the
Asthma Bother Profile and the Airways Questionnaire 20. J Asthma. 2004.
41(2):141-6. doi: 10.1081/jas-120026070
Blanco-Aparicio M, Vázquez I, Pita-Fernández S, Pértega-Diaz S, Verea-

Hernando H. Utility of brief questionnaires of health-related quality of life
(Airways Questionnaire 20 and Clinical COPD Questionnaire) to predict
exacerbations in patients with asthma and COPD. Health Qual Life
Outcomes. 2013 May 27;11:85. doi: 10.1186/1477-7525-11-85.
Grammatopoulou E, Skordilis E, Koutsouki D, Baltopoulos G. An 18-item

standardized Asthma Quality of Life Questionnaire-AQLQ(S). Qual Life Res.
2008 Mar;17(2):323-32. doi: 10.1007/s11136-007-9297-y
Osborne RH, Elsworth GR, Whitfield K. The Health Education Impact

Questionnaire (heiQ): an outcomes and evaluation measure for patient
education and self-management interventions for people with chronic
conditions. Patient Educ Couns2007;66:192-201
1.4 Etiology of Asthma 15
of those (the Asthma Quality of Life Score) deals cerned without detailed pathological study [89].
with symptoms, emotions, exposure to environ- Atopy refers to the propensity, usually genetic,
mental stimuli, and activity levels. Each item is for developing allergic responses to common
scored on a seven-point scale. A separate score is environmental allergens, usually via immuno-
used for children, to assess their stress levels and globulin E (IgE). In other words, the features of
quality of life [82–84]. There are other QOL scores asthma seen in atopic persons are the product of
based on race, culture, or literacy, and some used their genes and their environmental exposures.
specifically for research.
It seems likely that many persons with asthma
can, by following a carefully negotiated and pre- 1.4.1 Allergy and Asthma
scribed regimen, reduce the cost to themselves
and to society. They can lower their personal cost Most of the time, a strong association can be
by achieving as good control as possible and observed between allergy and asthma. People
avoiding triggers that lead to sharp deterioration. with asthma may belong to a family in which
Such management also reduces societal costs by many members have other allergic disorders such
reducing healthcare provider and ED visits and as hay fever or eczema (atopic dermatitis). The
hospital admissions and even the number of person with asthma may have rhinitis, eczema, or
deaths from asthma [36, 85, 86]. even anaphylaxis (a severe life-threatening aller-
The aim of all those involved in managing gic reaction) in addition to the asthma. Such peo-
asthma, whether educators, healthcare providers, ple are described as atopic. Most persons with
or individual and family members, should be to asthma also have evidence of allergy, as indicated
use the most effective therapy at the least cost. by positive skin tests, an increase in the overall
level in the blood of IgE and specific increases in
IgE to specific allergens, and increased eosino-
1.4 Etiology of Asthma phils in the blood and the airways.
Allergic asthma is by far the most common
Simple observation makes it clear that asthma is a form of asthma. In individuals with this form of
heterogeneous condition; in turn, that observation the disease, the asthma is due to IgE-type hyper-
suggests there may be more than one underlying sensitivity reaction, usually to inhaled allergens.
pathological mechanism. In fact, in asthma there This commonly has onset during childhood and
seems to be a complex interaction between aller- usually persists or recurs in adult life. See Fig. 1.2.
gies, genetic predisposition, and the physical and Non-allergic asthma is found in some adults
psychosocial environment. Described in outline and, very rarely, in children. Even in adults, it is
here, these are explored in detail in later chapters. much less common than allergic asthma [90, 91].
Words used here, such as genotype, pheno- Persons with non-allergic asthma usually exhibit
type, endotype, and atopy, require definition. the following characteristics. They:
Genotype is a person’s genetic constitution
and relates to all the genes possessed by that indi- • Have definite asthma, but without IgE
vidual. This is becoming increasingly well under- hypersensitivity
stood as more large-scale genome-wide • Generally do not have seasonal variation in
association studies become available [87]. symptoms
Phenotype is what we see in an individual with • Often experience the onset in adult life
asthma. For example, one phenotype might be • Tend not to remit, but to persist with
early-onset disease with severe exacerbations symptoms
[88]. There are of course many phenotypes, and it • Do not show the same variation with time as
is usually assumed that they are due to the inter- exhibited by allergic asthma
action of genotype and environment. Endotype is • Show a poor response to treatment other than
a subgroup of a phenotype that is not easily dis- with the use of systemic corticosteroids
Fig. 1.2 The
interrelationship
between asthma and
allergy
this may become clearer with genome-wide

1.5 Genetics and Environment analysis.
Developments in molecular biology overall,
1.5.1 Phenotype and Genotype but specifically in genome analysis, are begin-
Correlation ning to provide an understanding of some of
these issues. It seems that there are many differ-
The recognition that genetic factors are important ent relevant genes, present on different chromo-
in asthma is not new. Asthma runs in families. It somes, but in different proportions in different
would be more accurate to say that allergies run families. The precise genes present in an individ-
in families, and in any particular family, some ual will be one of the major determinants of the
members may have hay fever, some dermatitis or pattern of asthma. Researchers are attempting to
eczema, and some asthma. Individuals within the identify these, and it may well be that genes for
family structure may have more than one of those allergy, for airway reactivity, and for asthma are
conditions at any given time. all related. Their precise mix in an individual will
A child who has an atopic parent is twice as determine how the asthma presents and behaves.
likely to have asthma as a child who has neither This latter feature, seen in the individual, is the
parent atopic. The risk is slightly higher of hav- phenotype or clinical expression of the gene.
ing an atopic tendency with an atopic mother Confusion exists because the asthma pheno-
than with an atopic father. Atopy is a risk factor type may be mimicked by nongenetic disorders.
for asthma. Yet the wide variation in manifesta- Bronchial hyperreactivity (BHR) is an example
tions and severity from one person to another (a of phenotype-genotype confusion. At one time
variation which is seen even when they are BHR was thought to be specific for asthma, but it
closely related) has made precise estimation of is now recognized that BHR is seen in other dis-
genetic risk difficult. As noted earlier, some of eases including the common chronic obstructive
pulmonary disease (COPD). In other words, the In infancy and childhood however, what would
previous belief that asthma and COPD were sep- be considered a trigger in an older child or adult
arate entities that could be readily differentiated may actually be a cause of asthma and may interact
is simply not true. Rather, there is considerable with the genetic factors to set the scene for con-
overlap between them. tinuing asthma. In other groups, strong environ-
Pharmacogenetics, the study of the “genetic mental exposure—such as through occupational
determinants in the variable response to therapy,” exposure to Western Red Cedar, for example—
is an important new area of asthma research that may cause asthma with minimal or no genetic pre-
will eventually help in prescribing the most effec- disposition. This is an example of the asthma
tive remedy for an individual with asthma [92]. phenotype mimicked by a nongenetic cause.
For example, some people with asthma, with spe-
cific genetic traits, have a poor response to
inhaled corticosteroids [93]. Tests that would Points to Ponder
provide such information are not presently read- Common triggers of asthma
ily available: knowledge will however help us
understand so-called nonresponders, rather than • Allergens
assuming that they are not following • Infections
recommendations. • Irritants
For practical purposes, at the present time, a • Emotions
family history from first-degree relatives is
extremely important to identify this genetic pre-
disposition. This history must include occur-
rences of asthma, eczema, hay fever/allergic The main identified environmental causes of
rhinitis, and anaphylaxis. Care must be taken to asthma are exposure to allergens such as cat dander
explore the childhood history of adult relatives. and house dust mites in infancy [94], exposure to
For example, parents will often indicate in their passive cigarette smoke during pregnancy and
history that they themselves had “bronchitis” as a infancy [95, 96], and poor socioeconomic circum-
child and sincerely believe they do not have a his- stances [23, 54, 97]. Some food allergies have
tory of asthma. If it is possible to get information recently been shown to be important in the devel-
from the previous generation about those epi- opment of asthma in infancy and childhood, for
sodes of “bronchitis,” it will often turn out that example, to milk [98] and hen’s eggs [98–100].
this should have been diagnosed as asthma. Other While the relevance of early life events to the onset
markers of genetic predisposition, such as IgE of asthma has been well recognized for many
levels in umbilical cord blood, are useful in years, the specifics have been elusive. A common
research studies. confounder has been recall bias by studies in later
childhood or early adult life that focus on events
from many years earlier. Recently, large cohort
1.5.2 Environmental Issues studies (began in infancy and continued with fol-
low-up for many years) have helped to resolve
Genetic predisposition is not the only issue of some difficulties. For example, Sears et al. [101]
concern. For children, there may be an environ- followed 613 children born in New Zealand from
mental cause in addition to the genetic predispo- April 1972 through March 1973 all the way through
sition, and this has only recently been recognized. to age 26. This unselected birth cohort completed
In the past, focus was placed on environmental questionnaires, pulmonary function testing, bron-
triggers, which were defined as anything that chial-challenge testing, and allergy testing. About
could lead to an episode of asthma. one in four had wheezing in adult life.
Those with persistent or relapsing symptoms Th2 response characteristic of asthma [106].
were more likely to: Thus toxins brought into the home by pets may
protect against the development of allergy.
• Be sensitized to house dust mites Other studies have shown a possible reduced
• Have airway hyperresponsiveness risk of asthma in children who spend their early
• Be female life on farms, again perhaps due to endotoxin
• Smoke exposure [107].
• Have early onset of wheeze Viral infections may also have paradoxical
effects. In preschool children, viral infections
Despite similar information in other studies, are the most common trigger of an episode of
no universal strategy for prevention of asthma wheezing. Some specific respiratory infections
has emerged. It is common to find that expo- are correlated with asthma severity and linked
sure to dust mites is one of the most potent to susceptibility of later infections which are
asthma-producing allergens and that this expo- potent triggers of asthma [108]. Then again,
sure is a risk factor for bronchial hyperrespon- recent evidence suggests that exposure to older
siveness or BHR [94, 102, 103]. The National siblings and in daycare facilities may lessen
Heart, Lung, and Blood Institute (NHLBI) the likelihood of asthma in genetically predis-
guidelines [11] note that exposures to high lev- posed children [109–111]. These findings,
els of house dust mite antigen and environmen- interpreted against the background of a general
tal tobacco smoke are associated with increased increase in asthma in the western world, have
incidence of asthma among infants. A study of led to speculation that lifestyle issues may be
696 newborns in Europe at increased risk of relevant.
atopy showed a reduced incidence of sensitiza- The potential role of exposure to bacterial
tion to dust mite allergens at 1 year with the endotoxin and viral infections in protecting
use of mattresses that were impermeable to against asthma has been described as the
house dust mites [104]. Unfortunately, it has “Hygiene Hypothesis” [107, 108, 112, 113]. This
not yet been shown that reduction in exposure hypothesis is one explanation for the increase in
to house dust mites in infancy will prevent the the incidence of asthma in developed countries. It
onset of asthma. assigns a causal role to “improvements” in soci-
As far as pets are concerned, there is apparent ety, particularly changes in early childhood with
confusion in the current literature between their an emphasis on cleanliness and smaller family
roles, firstly in the onset of asthma and, secondly, size. The suggestion is that fewer infections and
in the persistence of the disease [103, 105]. There less exposure to dirt and endotoxins impair
is a clear association in adolescents and adults immune development. This hypothesis explains
between sensitization to pets and both current some, but not all, of the recent data, and it is not
wheezing and BHR. Yet cohort studies have yet proven. It is possible that advances in genetic
shown a lower risk of asthma in children exposed knowledge may allow better understanding of
to pets in early life, in effect suggesting that pets genetic/environmental interactions. Perhaps
might be protective. In a review of these studies, some children, with one genotype, when exposed
it is speculated that it is not the pets that are pro- to infection or endotoxin will exhibit heightened
tective, but some associated factor. susceptibility to allergy. Others may be harmed
For example, bacteria produce toxins, and by too much infection in infancy or by one or two
endotoxins in the cell wall are released when specific infections.
those walls disintegrate. Toxins can harm. For The educator must move carefully when
an example outside asthma, the deadly disease reviewing the complex literature relating to the
botulism is caused by a toxin. Exposure to bac- onset and persistence of asthma. For persons with
terial toxins is thought to be a major factor in asthma, or infants with recurrent wheezing, atten-
developing immune responses other than the tion to the environment remains important.
Allergic sensitization requires assessment, and An example would be Wickman’s study of

where exposure can be reduced, such as to pets, it children whose families were provided with
should be. The benefits of such reduction are guidelines that recommended breastfeeding,
clear. It is possible that the paradox of exposures no exposure to tobacco smoke, and homes
being protective at one age and then harmful at without dampness and with good ventilation.
another will be explained in the future by detailed Families that followed these guidelines had a
genetic analysis. Cohort studies give invaluable 12.6% incidence of wheezing and 6.8% of
information on populations, but their findings asthma when compared with 24.1% and 17.9%,
must be interpreted cautiously in individuals. respectively, for families that did not follow
Non-allergenic triggers [114] also exist, such them. Further, for children without allergic
as cold air, exercise, tobacco smoke, wood and parents, there was a twofold reduction in
industrial smoke, and many different environ- asthma, while children with allergic parents
mental exposures. Only tobacco smoke exposure reduced their risk of asthma by a factor of 3
has been shown to be causal for the onset of when these guidelines were followed [123]. In
asthma, although the others are very relevant to another study, the parents of 58 infants at
its persistence. Outdoor pollutants can trigger increased risk of asthma and allergy were given
asthma and worsen symptoms [115–117], but advice on feeding and avoidance of house dust
whether outdoor pollutants can cause asthma is a mite. The outcome, in terms of allergy and
different question. In a systematic review, asthma in the children, was compared to 62
Gowers et al. [118] concluded that some forms of children whose parents were not given this spe-
outdoor air pollution might play a role in suscep- cific advice. It was confirmed that allergic dis-
tible individuals in the causation of their asthma. eases could be reduced [124].
The conclusion was very cautious, stating that The risk factors for asthma are:
this was a small effect on a small proportion of
the population. • A parental history of atopy
The fact that asthma is a combination of • Nature of the allergen
genetic and environmental factors [119–121] • Respiratory illness before age 2
does pose some practical implications. There is
little that can be done about the genetic tendency, GINA lists the risk factors in two categories,
but where there is a known genetic predisposi- host and environmental, and further groups the
tion, it is important to offer counseling, for latter into causal and contributing factors with
example, during pregnancy, with a focus on allergens and occupational sensitizers included in
reducing exposure to tobacco smoke. It is tempt- causal factors. See Table 1.4.
ing to suggest that pregnant women avoid those
foods that might lead to allergies, but this may
not be helpful for the child. An extensive review Table 1.4 Genetic and environmental risk factors for
concluded that an antigen avoidance diet for a asthma [13]
high-risk woman during pregnancy is unlikely to Host: predisposing Causal Contributing
reduce substantially her risk of giving birth to an Atopy Allergens Respiratory
atopic child. Moreover, such a diet may have an Genetic • Indoor infections
Airway • Outdoor Small size at birth
adverse effect on maternal and/or fetal nutrition hyperresponsiveness Occupational Diet and
(122). There should be strong encouragement Gender sensitizers medications
and support for breastfeeding. However, infants Ethnicity Obesity
can be sensitized to potent food allergens in Air pollution
• Indoor
breast milk. Counseling should be maintained • Outdoor
after birth. Smoking
Despite theoretical confusion, it is possible • Active
for anticipatory guidance to make a difference. • Passive
1.6 Approaches to Asthma The process of guideline development var-

ies. In general, the first step is to identify all the
Before treating a person who has asthma, every relevant evidence and to discuss its signifi-
healthcare practitioner (HCP) must be familiar cance. Participants in the discussion are
with the latest recommendations for diagnosis regarded as “experts,” and there should be a
and treatment of this condition. The recommen- very open process for identifying them and a
dations are summarized and published as wide range of latitude in determining who is
“guidelines”. considered an “expert”. Conflicts of interest in
those developing guidelines should be declared.
Some committees producing guidelines will
1.6.1 Guidelines assume that consumers are experts, while oth-
ers will not make this assumption. The authors
Guidelines exist for a number of diseases, and of this book believe that consumers are always
they tend to be updated at different times. Asthma experts on how disease and treatments affect
guidelines have been updated fairly recently, and their lives.
this section provides a brief overview of their Developers of guidelines will vary in their
major emphases. attitude to evidence. They will also vary in their
“Guidelines” exist under a wide variety of attitude towards implementation. Sometimes
names, such as Clinical Practice Guidelines, Care they will assume that the very development and
Maps, Care Plans, and so on. There are differ- publishing of guidelines is of itself a sufficient
ences, often subtle, between the various titles, the start towards implementation. At other times,
intended audiences, and how they might be used. very detailed steps will be developed and pub-
Guidelines were first developed when it lished to help with the implementation.
became clear that there was a huge gap between One final important topic in guideline devel-
the scientific knowledge available about a medi- opment is the funding of the process. The costs
cal condition and the implementation of that associated with the extensive literature required,
knowledge in everyday practice. They were the meetings of experts, the discussion groups,
intended to serve as a way to quickly translate and publishing have all to be borne by one group
scientific research into clinical actions with the or another. If industry provides the funding, then
aim of benefiting individuals with asthma. It is the extent of its influence over the final product
assumed that no physician or other healthcare needs to be clearly articulated and evaluated.
professional can be an expert in every aspect of This is a completely separate issue from the dec-
care. Guidelines allow access to a succinct state- laration of individual conflicts of interest men-
ment of the evidence available at one moment in tioned above.
time. Guidelines are an important part of “knowl-
edge transfer” in ensuring the results from
research are available to those with asthma as 1.6.2 NHLBI Guidelines
soon as possible.
Guidelines can become obsolete as new evi- The National Heart, Lung, and Blood Institute
dence becomes available. Typically, they usually (NHLBI) is one of the federally funded National
list areas of agreement and also identify areas of Institutes of Health. NHLBI Guidelines are
disagreement and areas for further study. Further, immediately relevant to all healthcare profession-
they are not intended to control every detail of als planning to obtain their AE-C designation.
care. It is recognized that while there is common- The first NHLBI Expert Panel Report on
ality from one person to another, yet there are so Asthma was released in 1991 and has been
many individual differences that, within limits, it updated from time to time. The most recent com-
is important that healthcare professionals and prehensive document, the Expert Panel Report 3
individuals have some freedom to make choices. (EPR-3) cited earlier, was published in September
2012 [11]. Since then there have been focused The Panel listed these key points:
updates on specific topics, most recently in 2020
[125]. Other bodies have also produced helpful • Asthma is a chronic inflammatory disorder of
reports, particularly GINA [2]. Reference will be the airways.
made to relevant and useful parts of all these • Immunohistopathologic features are
documents. important.
It is important that the reports from official • Inflammation leads to airway hyperrespon-
bodies and healthcare organizations summarize siveness, airflow limitation, respiratory symp-
evidence fully and fairly and base their recom- toms, and disease chronicity.
mendations on that evidence. The orderly process • Some of those with asthma have permanent
followed in the 2012 publication is a model. Here structural changes to the airway.
is the process in sequence: • Importance of gene-environment interactions.
• Atopy is the strongest identifiable predispos-
(1) Completing a comprehensive search of the ing factor for developing asthma.
literature
(2) Conducting an in-depth review of relevant The key differences from previous reports are
abstracts and articles (and we quote again):
(3) Preparing evidence tables to assess the
weight of current evidence with respect to • The critical role of inflammation has been fur-
past recommendations and new and unre- ther substantiated, but evidence is emerging
solved issues for considerable variability in the pattern of
(4) Conducting thoughtful discussion and inter- inflammation, thus indicating phenotypic dif-
pretation of findings ferences that may influence treatment
(5) Ranking the strength of evidence underly- responses.
ing the current recommendations that are • Gene-by-environmental interactions are
made important to the development and expression
(6) Updating text, tables, figures, and references of asthma. Of the environmental factors, aller-
of the existing guidelines with new findings gic reactions remain important. Evidence also
from the evidence review suggests a key and expanding role for viral
(7) Circulating a draft of the updated guidelines respiratory infections in these processes.
through several layers of external review, as • The onset of asthma for most patients begins
well as posting it on the NHLBI web site for early in life with the pattern of disease persis-
review and comment by the public and the tence determined by early, recognizable risk
NAEPP Coordinating Committee factors including atopic disease, recurrent
(8) Preparing a final report based on consider- wheezing, and a parental history of asthma.
ation of comments raised in the review cycle • Current asthma treatment with anti-
inflammatory therapy does not appear to pre-
The evidence that justified the recommenda- vent progression of the underlying disease
tions was ranked as follows: severity.
A ─ Randomized controlled trials (RCTs) with In the report, asthma management is seen as
rich data consisting of four components: careful assess-
B ─ RCTs with limited data ment and monitoring; education as a partnership;
C ─ Non-randomized trials and observational environmental control and treatment of comor-
studies bidities; and medications. The concepts of sever-
D ─ Panel consensus judgment ity (the intrinsic intensity of the disease process)
and control (degree to which manifestations of
asthma are minimized) are closely linked. In turn, as an alternative therapy to ICS in mild persistent
both are linked to responsiveness, which is the asthma. There are an increasing number of immu-
ease with which the asthma is controlled by ther- nomodulators [126], still mainly monoclonal
apy. Severity and control should be assessed ini- antibodies such as omalizumab. Each agent
tially and then later, after therapy has shown seems to be particularly useful with specific phe-
benefit. Previously, comorbidities that might notypes and is used with persistent symptoms
interfere with asthma management were identi- despite full therapy with other agents and good
fied as rhinitis, sinusitis, and gastroesophageal environmental control.
reflux. To this list, the report adds as important Methylxanthines are another long-standing
comorbidities allergic bronchopulmonary asper- treatment for mild persistent asthma. They are no
gillosis (ABPA), obesity, obstructive sleep apnea longer a preferred treatment given their high inci-
(OSA), and stress. dence of side effects, requiring both symptom
The type of asthma also affects management, monitoring and regular measurement of blood
with “type” being broadly described as intermit- levels. They may have a limited use as adjunctive
tent and persistent. The classification “mild inter- therapy with ICS.
mittent” has been removed, as persons with The main medications for quick relief are the
intermittent asthma, even if generally mild, can SABAs. Anticholinergics provide an additive
have severe exacerbations on some occasions. benefit to a SABA: the SABAs relax the muscles,
Persistent is subdivided into mild, moderate, and while the anticholinergics prevent the muscles
severe. Attention to environmental aspects is still from tightening. SABA drugs are safe, but
considered important, but the 2012 report noted increasing or increased use indicates poor control
that the new evidence strengthens recommenda- and the need for more effective long-term ther-
tions that asthma control is improved with apy. While systemic corticosteroids are not rapid-
reduced exposure to indoor allergens. A multifac- acting, they are used along with SABA in
eted approach to environmental control is moderate and severe exacerbations.
essential. Most of the medicines (SABA, LABA, and
Medications are placed in two broad catego- ICS) are given by the inhaled route. For those
ries: long-term control and quick relief. The main delivered by metered-dose inhaler (MDI), a
aim of such therapy is to “prevent and control “spacer” is required. The spacer or holding cham-
asthma symptoms, improve quality of life, reduce ber extends the MDI away from the mouth and
the frequency and severity of asthma exacerba- retains the large particles of medication, allowing
tions, and reverse airflow obstruction.” a greater proportion of small particles to enter the
Medications used in long-term control are inhaled airway.
corticosteroids (ICS), long-acting beta agonists Many persons with asthma, or their families,
(LABAs), leukotriene modifiers, immunomodu- will ask about complementary and alternative
lators, and methylxanthines. Newer medicines medicines. None of these compounds is a substi-
are being developed, and some are in use that tute for any medicine mentioned above, and there
help people with asthma by altering the immune is no, or insufficient, evidence to make recom-
response. These have been described as immuno- mendations. Acupuncture is not recommended
modulators, and currently the one used most fre- for asthma. Herbal preparations may contain sub-
quently is omalizumab that blocks IgE action. At stances that are harmful and/or interfere with the
one time, cromolyn sodium and nedocromil were action of prescribed medications.
in use for mild asthma, but it was always recog- The severity of the asthma will determine the
nized that their potency was low. Today, ICS are initial prescription (the medications, doses, and
the mainstay of management and may be com- schedules). The level of asthma control will
bined with a LABA. The latter are never used on determine how these are adjusted. This is done in
their own. Leukotriene modifiers may be used as steps, following a six-step approach. Therapy is
adjunctive therapy, along with ICS, and possibly then stepped down (i.e., reduced) to the point
where the disease remains controlled with the on the use of bronchial thermoplasty was not
minimum amount of medication. strong, and a very limited role was envisaged.
The overall aim is to reduce impairment. Similarly, many cautions are placed around the
Specific aims are to prevent symptoms, have only use of immunotherapy. One item that drew atten-
infrequent use of SABA (2 days a week or less), tion was the use of intermittent inhaled cortico-
maintain normal pulmonary function, and main- steroids in the treatment of intermittent asthma.
tain normal activity. All of this should be achieved This break from the mantra of “ICS every day for
to the satisfaction of the person with asthma and everyone with asthma” was welcome and also
his or her families. Monitoring and follow-up is realistic in the expectations we have of people
essential. It should be remembered that because with asthma.
asthma is a chronic disease, persistent asthma The 2020 Focussed Updates provided details
will require daily therapy. on “the need to integrate the new evidence-based
This group of recommendations differs in a recommendations into a comprehensive approach
number of ways from previous iterations. to asthma care using the EPR-3 step diagrams.”
Management recommendations for those below One important new topic—that of the role of
12 years are no longer grouped together; they are immunomodulators—is addressed in the GINA
now subdivided, into 0–4 years and 5–11 years. update. That update provides details on those
The decision on choice of initiation therapy is currently available, all of them being monoclonal
based on assessment of both impairment and risk antibodies. This is both an important topic and an
components of severity. A number of other exciting development and is described in detail in
changes will be mentioned in detail later, includ- Sect. 6.4.6. However, all of the compounds avail-
ing the need to consider separately both QOL and able are new, so their use requires both discern-
functional issues. ment and care and avoidance of the tendency to
In addition to some racial and ethnic dispari- “jump on the band wagon.”
ties, there is a constant reminder of the impor-
tance of identifying and treating comorbidities.
The 2020 report [125] was asked to focus on 1.6.3 Pediatric Guidelines
six specific topics and not to revise all of the pre-
vious recommendations. Hence in Chaps. 5 and The US Guidelines for the Diagnosis and
6, material from both reports will be used to Management of Asthma are applicable to chil-
guide evidence-based practice. The 2020 topics dren and adults and recognize that asthma
include: affects all ages [11]. As noted, the issues affect-
ing children are subdivided into those for chil-
1. Use of fractional exhaled nitric oxide testing dren aged 0–4 years and those aged 5–11 years.
in diagnosis and management The differential diagnosis of asthma in children,
2. Indoor allergen mitigation in management especially those under 4 years, is wider than in
3. Use of intermittent inhaled corticosteroids in older children and young adults. However, addi-
treatment tional care is required with children, both to
4. Use of long-acting muscarinic antagonists improve their quality of life throughout child-
5. The role of subcutaneous and sublingual
hood and to ensure that they reach adulthood in
immunotherapy in the treatment of allergic good health. Help with the specific issues per-
asthma taining to pediatric asthma is available in a
6. Use of bronchial thermoplasty to improve
recent review of guidelines from a variety of
outcomes sources [127]. Many adult pharmacologic thera-
pies are used in children, with only minor varia-
The inclusion of an item does not mean sup- tion in dosage. The dose should be tailored more
port; rather, it indicates that clarification of the to the assessed severity than to the physical size
evidence was needed. For example, the evidence of the child.
The onset of asthma most often occurs in 1.6.4 COVID-19 and Asthma

childhood, and between 50% and 80% of asthma
develops before the age of 5 years. In the USA, The COVID-19 pandemic has caused extreme
there are about 5.5 million children (7.5%) below anxiety in those with asthma and also among
18 years with asthma, with approximately educators and healthcare personnel. It has also
744,000 (about 3.8%) of them less than 5 years meant services have been limited and often pro-
old [18, 128]. Asthma is responsible for extensive vided online. How much these new ways of pro-
time lost from school and is particularly preva- viding education will be used in the future
lent in areas of poverty and in inner cities. It remains to be seen. It is safe to conclude that
affects the child’s life at home, but may also when the pandemic is over, there will not be a
reduce ability to participate in sports, attend return to the old way of doing things—some of
school trips, participate in physical education or the new procedures will remain in place, while
playground activities, or play a musical wind others, possibly less cost-effective, may be
instrument. Once good control is achieved, all discarded.
these activities are possible for children with GINA has provided some guidance [131]. It
asthma. Asthma is often overlooked in children. clearly states that “People with asthma are not at
The criteria for diagnosis, and the wide differen- increased risk of acquiring COVID-19.” The evi-
tial diagnoses in younger children, are described dence supporting this statement is that:
in Chap. 4.
When assessing children with asthma, a full • Systematic reviews have not shown an
environmental history should be done. While this increased risk of COVID-19 in people with
will obviously look at the child’s home, it must asthma.
include school, daycare facilities, and friends and • Handwashing, masks, and social/physical dis-
family whom the child visits frequently. tancing have reduced the incidence of other
ICS are the mainstay of treatment of asthma, respiratory infections, including influenza, in
but there are specific concerns with these drugs 2020.
because of the paucity of formal studies in chil-
dren. While the impact of inhaled corticosteroids The role of the educator remains important in
on the child’s growth appears to be minimal, the the life of people with asthma. Overall, people
evidence is however confusing [129]. Decreases with asthma are not at increased risk of death
in the growth rate appear to be temporary and related to COVID-19, but the risk of death was
unlikely to have an effect on final growth height. increased in those who recently had oral steroids
However, atopy itself has an effect on growth and [132]. “Therefore, it is important to continue good
can increase the risk of short stature by two to five asthma management (as described in the GINA
times [130]. Nevertheless, linear growth should report), with strategies to maintain good symptom
be monitored in children on inhaled corticoste- control, reduce the risk of severe exacerbations
roids. Once the asthma is under control, the dose and minimise the need for oral corticosteroids.”
of medication should be reduced to the lowest Other COVID-related advice:
effective level. Formal assessment using spirom-
etry should be done as soon as possible, possibly 1. Medications
as early as 3 or 4, but more likely at 6 or 7. a) Advise patients to continue taking their
Where the 2020 update applies to children, prescribed asthma medications, particu-
details are given. The relevance of the use of inter- larly inhaled corticosteroids.
mittent inhaled corticosteroids in children, whose b) For patients with severe asthma, continue
asthma is often intermittent, is noted. The newer biologic therapy or oral corticosteroids if
biologic immunomodulators are relevant to chil- prescribed. Make sure that all patients
dren with severe persistent asthma, although cur- have a written asthma action plan, advising
rently limited to those over 6 years of age. them to:
Increase controller and reliever medication sician, healthcare provider, nurse, pharmacist,
when asthma worsens and others) and will view this relationship as an
Take a short course of OCS when appro- effective way to help them manage their chronic
priate for severe asthma exacerbations conditions.
Avoid nebulizers where possible, to reduce Individuals seldom think about how health-
the risk of spreading virus care providers will relate to one another or how
Preferably, use pressurized metered dose well they are educated in current trends and in a
inhaler via a spacer except for life- specific disease and how the arrangements of
threatening exacerbations their personal healthcare plan, or the healthcare
Add a mouthpiece or mask to the spacer if system as a whole, relate to their disease. Some
required of these issues will be dealt with in the next
2 . Infection control section.
a) Avoid spirometry in patients with con-
firmed or suspected COVID-19, or if com- 1.6.5.1 General Approach of Health
munity transmission of COVID-19 is Systems
occurring in your region. For the most part, early twentieth-century health-
b) Follow aerosol, droplet, and contact pre- care consisted of physician visits followed by a
cautions if spirometry is needed. trip to a pharmacy. In some cases, the pharmacy
c) Consider asking patients to monitor PEF at visit was not needed as the physicians may also
home, if information about lung function have dispensed the medications. For serious ill-
is needed. nesses, a nurse may have visited the home, or the
d) Follow strict infection control procedures individual may have been admitted to a local
if aerosol-generating procedures are hospital.
needed, such as nebulization, oxygen ther- As the twentieth century progressed, there
apy (including nasal prongs), sputum were improvements both in the effectiveness of
induction, manual ventilation, noninvasive specific medical treatments and many organiza-
ventilation, and intubation. tional changes. Within medicine, there was less
reliance on family physicians and an increase in
Above all GINA advises us all to “Follow the number and types of specialists. Nursing, the
local health advice about hygiene strategies and one profession traditionally associated with med-
use of personal protective equipment, as new icine, was joined by many other healthcare pro-
information becomes available in your country or fessions, including physiotherapists, occupational
region.” therapists, respiratory therapists, physiologists,
social workers, and therapists of many different
skills; and they all have an important role in
1.6.5 Organization of Care healthcare. These groups have increased in num-
ber and significance, and there has also been spe-
There will always be some people who prefer to cialization within groups. For example, some
attend the ED for urgent care—possibly because respiratory therapists specialize in a specific area
they do not have a regular healthcare provider, or of medicine, such as care of children, while oth-
do not want to deal with the same healthcare pro- ers work in intensive care units (ICUs).
vider on a regular basis since that person might Asthma educators are a new type of healthcare
give them unwelcome advice about asthma con- professional, with background training in one of
trol. Such persons will always have many reasons many healthcare disciplines, together with addi-
for preferring a visit to emergency. tional specialized knowledge of asthma that is
However, others will prefer to achieve a pro- supplemented by training in patient education.
ductive long-term professional relationship with They may be found in any healthcare setting and
one or more healthcare providers (such as a phy- may confine practice to asthma education or may
combine asthma education with the more general delivered in many sites other than a physician’s
practice of their discipline. They may also work office or a hospital.
more widely as respiratory educators. In addition to the healthcare providers, it is
While these changes in the professions were necessary to consider also those with asthma,
occurring, treatments, including medications, their families, and their whole social network in
increased both in effectiveness and in cost and the overall organization of care. A convention-
are now very expensive. These dual increases led ally structured healthcare team set up to deal
to many changes in insurance coverage, includ- with a chronic condition might include a physi-
ing the introduction of national schemes such as cian or nurse practitioner (a nurse who prescribes
Medicare and Medicaid. The final decades of the and does primary care), nurse, pharmacist, thera-
twentieth century have seen the evolution of pist (respiratory therapist for asthma), social
many varieties of health maintenance organiza- worker, psychologist, physiotherapist, and
tions (HMOs). “The delivery, organization and others.
financing of healthcare is a complexly adapting As described, the team implies that the person
system” [133]. being treated is a passive participant rather than
The current trend is to focus designated an active member. However, experience suggests
resources on specific diseases. Disease manage- that this person should, instead, be an active and
ment programs have been developed with the participating member of the team.
twin aims of improving outcomes and reducing Thus, a proper team to deal with a chronic
costs. Thus, the emergence of cardiac centers, condition, such as asthma, would include:
which include both cardiac surgery for end-stage
disease, and cardiac rehabilitation centers; of dia- • The person with asthma and his/her family
betes centers with a focus on education; and so • A physician and/or another healthcare
on. A system-wide approach to asthma fits into provider
this scenario. In the twenty-first century, all of the • Healthcare providers such as an asthma edu-
centers, including those for asthma, will make cator and a pharmacist
extensive use of virtual and online resources. As • Other healthcare providers, as needed
an unanticipated result of COVID-19, those liv-
ing in rural areas, if they have high-speed Internet Other healthcare providers may be involved in
coverage, will have the same access to high- some cases, depending on severity. They will
quality health education as those living next door include, among others, respiratory therapists,
to a prestigious medical center. psychologists, social workers, physiotherapists,
Where there is such system-wide support, teachers, and specialists in allergy, pulmonology,
there is great hope for everyone with asthma. sports, and exercise activity.
Even when such support is absent, there is great The person at the center of this team is the per-
hope that health outcomes can be improved, son with asthma and the family. The team will
wherever both the agency providing healthcare recognize the person’s importance and will offer
and individual healthcare providers accept the a variety of professional expertise. Since each
responsibility to include prevention and professional will view the individual’s problem
education. from a different point of view, the advice given
will be multifaceted and comprehensive.
1.6.5.2 Healthcare Professionals However, it must be noted that the major (and
As mentioned earlier, traditional healthcare has final) responsibility for taking and adjusting
concentrated on the roles of the physician and the medications, and for making any needed changes,
hospital for inpatient and emergency department rests with the person and his or her family.
care. There is a growing recognition that health- In asthma, an organized system for provision
care has a far wider scope—many other health- of care will lead to a number of benefits
care providers are involved, and healthcare is including:
• Improved assessment and diagnosis 1.7.1 The Issues

• A methodical approach to treatment
• Education and development of self-Asthma is a chronic condition. Strategies used by
management plans for those with the both those with asthma and by healthcare profes-
condition sionals in managing a chronic condition are quite
• Access to information different from those for an acute situation. In a
• Regular follow-up to maintain and reaffirm chronic condition, the complicated interaction
the need for long-term treatment between the family/person with the condition, the
• Further regular follow-up to determine the condition itself, and other healthcare providers
need for changes in treatment becomes fundamentally different from the inter-
• Modification of treatment with advances in action that occurs in an acute disease. Those with
knowledge a chronic condition may additionally be very
knowledgeable and rightly demand more control
1.6.5.3 Personal Responsibility over their treatment.
The person with asthma, and the family, must be Healthcare in North America has had most
responsible for monitoring the severity of the success in dealing with acute diseases. Those
asthma. This becomes even more important with with long-term conditions or disabilities meet
a chronic long-term condition. They will know various barriers in the system and in the attitude
when their loved one with asthma is in trouble of some healthcare providers. Insurers may ques-
and will be able to take early corrective action tion the provision of expensive medication for
rather than later crisis reaction. They will be ambulatory care. The issue of “pre-existing con-
able to make minor adjustments in treatment, to ditions” is currently under political review in the
plan appropriate interventions themselves, and USA in terms of overall healthcare coverage,
to deal with situations such as exercise. They including medication coverage.
will be able to assess the effect of a new envi- Individuals with a chronic condition may not
ronment and be full partners in the valuable see themselves as having a disease and may go
assessment of treatment. They will be able to do for long periods without giving much thought to
all of these things if they are educated about their healthcare. This desire to “get on with life,”
their condition and the way it affects them. often referred to disparagingly as “denial” by
Individuals need to be made aware of their roles professionals, can actually be healthy. Those with
and responsibilities in the management of chronic conditions themselves realize there is
asthma. Hence the educator has a role to play in much more to life than their condition. However,
helping everyone with asthma become self-reli- in almost every chronic condition, there is a need
ant and self-managed with guidance from the for daily discipline: to take medications, to avoid
asthma care team. situations which will cause deterioration, and to
consider specific conditions when dealing with
such issues as changes at work, relocating, choos-
1.7 Education of Persons ing a house, and dealing with family structure.
with Asthma There may also be long-term reduction in income.
Some of the words used when discussing
The process of educating people about their dis- chronic conditions are pejorative. These include
ease used to be done by healthcare providers “normal,” “disability,” and “handicap.” The word
(HCPs). Today, the asthma educator works, along “normal” is often used by physicians and other
with the HCP and other members of the medical scientists in a statistical sense, but individuals
team, to provide much of that education and with chronic conditions find its opposite, “abnor-
ongoing support. The educator’s functions are mal,” to be an offensive word. The words “dis-
briefly described here. ability” and “handicap” have their own negative
connotations. In addition to this, many persons A key component in long-term management

with chronic conditions, including those with includes a partnership with the person who has
asthma, exhibit quite a wide variation in the the condition. This requires a full exchange of
degree to which they may be affected. information, an understanding of expectations by
Chronic disorders abound in medicine, and both sides, and the responsibilities of each party
one of them, diabetes mellitus, has useful paral- [135, 136].
lels to asthma. Diabetes mellitus requires: People with chronic conditions, including
those with asthma, require education and help in
• Daily medication, sometimes involving order to live a normal life. Some restrictions,
injections such as avoidance of vulnerable situations and
• A need for lifestyle changes (particularly in the regular use of medication for prevention, may
diet) be necessary. They will also need to develop the
• A quick response to a sudden change, such as skills to recognize the signs of deterioration and
that caused by an acute illness to cope with it. They must also be able to recog-
nize when they are sick enough to need profes-
In diabetes mellitus, experience shows that sional help.
educated—i.e., knowledgeable and empow- Poor treatment adherence is a major problem
ered—individuals achieve a better degree of dis- with asthma. Studies often focus on subtle differ-
ease control, and a vastly improved quality of ences between one anti-inflammatory medication
life, than those who simply follow instructions. and another and ignore the larger issue of why
Disease control and quality of life are poorer still people with asthma will or will not take prophy-
in those who ignore instructions. lactic treatment. The addressing of this issue is
Much has been made in recent medical litera- extremely important in improving the outcome of
ture of the re-recognition that asthma has an individuals with asthma.
inflammatory basis. This provides support for the Many barriers militate against adherence.
avoidance of environmental factors which may One of the easiest to overcome is a lack of
lead to chronic inflammation and for the use of knowledge about why certain medications are
effective medications such as inhaled steroids, necessary and how they should be taken. Other
which can deal with the inflammation when taken barriers include cost, the inconvenience of regu-
on a regular prophylactic (preventive) basis. The lar treatment, and fear of side effects of some
recognition that asthma is based on airway medications. All these can be addressed in an
inflammation is at least as important as the recog- educational program.
nition that it is chronic. Even with adherence, a major barrier to
Many factors need to be considered in man- achieving control of the asthma lies in the incor-
agement in addition to an appropriate prescrip- rect use of the various devices designed for
tion for a chronic condition. These include: inhalation of asthma medications. Individuals
with asthma need frequent teaching and moni-
• Perception [134] toring in the correct use of the many devices
• Understanding available.
• Attitude There is definite evidence of the benefits to be
• Literacy overall and health literacy obtained from patient education [63, 67, 72, 135,
• Education 137–139] whether in self-management and cop-
• Individual treatment regimen ing [35, 140, 141], in school attendance or
• Identification of triggers reduced ER visits or hospitalizations [33, 62,
• Avoidance of triggers 141–144]. Education reduces the fear and builds
• Objective assessment confidence in the individual’s ability to manage
• Follow-up the disease [140].
1.7.2 Role of the Asthma Educator ing optimal pharmacologic therapy.” It should be

noted this has the highest level of supporting evi-
Why educate people with asthma? As far back as dence. GINA [13] lists “education of patients to
1975, the American Nurses Association stressed develop a partnership in asthma management” as
that patient education is both the professional and the first and most important part of a six-part
legal duty of a nurse [145]. By 1988, the NHLBI, management plan.
in a workshop entitled Asthma Education: A Many early attempts at education sought to
National Strategy [146], strongly emphasized teach the concepts of self-management by stress-
asthma education as a prerequisite for manage- ing a detailed knowledge of asthma [145]. But it
ment of this condition. This included not only soon became clear that an increase in knowledge
individual/public education but also professional did not lead to acquisition of the skills necessary
education and a national coalition of agencies for self-management and that, often, what was
and organizations, both professional and volun- learned was not translated into practice. In a
teer, to promote a national education plan. The review session, those with asthma would list
Joint Commission on Accreditation of Healthcare what had to be done during an asthma episode,
Organizations (JCAHO) listed individual and but seemed unable to actually do what was
family education as a priority in 1993. In every required when confronted with a crisis situation.
report after that, JCAHO has emphasized educa- Initial “education” sessions were done by phy-
tion of the individual. It is a critical component in sicians who tried to educate persons with asthma
their criteria for Disease-Specific Care through information packages, brochures, and
Certification. JCAHO standards also require leaflets. This did not have the necessary and
interdisciplinary collaboration [147, 148]. expected impact. The time required to teach peo-
In its 1993 publication, Healthy People 2000 ple with asthma was often a disincentive to physi-
Review 1992 (PHS#93-1232-1 August 93), the cians. When nurses took over the job of education,
US Department of Health and Human Services it was noted that the response was far better
stated that one goal towards improving the health towards nurses who themselves had asthma than to
of the nation should be to increase to 50% the nurses who did not [95, 152]. But again, the results
number of persons with asthma receiving formal did not meet the hoped-for expectations. Education
asthma education. In hindsight, this proved to be seminars were conducted for healthcare providers
too ambitious, since subsequent research found involved in working with people with asthma, but
that only 8% of persons with asthma had received those too were found to be insufficient. The semi-
such education. In Healthy People 2010, the goal nars resulted in an increase in knowledge for the
was to have 50% of people with asthma receive healthcare provider, but did little to advance an
formal asthma education. In the most recent understanding of the triggers of asthma and how to
biennial report, that goal was revised from the avoid them. Nor did they have a lasting effect on
baseline in 2008 of 12.1% to a more realistic those who actually had asthma [153].
14.5% [149]. Time and a better understanding of the task
International Consensus Guidelines [150] also brought change and an appreciation of the role of
emphasize asthma education and self-the educator. Then came the realization that it
management as integral components of asthma required a specially trained healthcare profes-
management. The NIH publication Nurses: sional [64, 154, 155] who not only understood
Partners in Asthma Care (1995) [151] featured asthma and its pathology but was able to impart
education of those with asthma as one of the four that knowledge in an appropriate, customized,
components of asthma management. The NHLBI and effective manner. That person could teach,
Expert Panel Report on Asthma [11] states that provide support and counseling, and encourage
“Therapeutic strategies should be considered in using a systematic approach that was tailored to
concert with clinician-patient partnership strate- individual patterns of learning and behavior.
gies; education of patients is essential for achiev- Thus was born the asthma educator.
1.7.3 Skills of the Asthma Educator • Strategies for dealing with individuals of dif-
ferent ages, developmental stages, and
The asthma educator has to be well-versed and backgrounds
proficient not only in the field of healthcare but • An understanding of how people learn and
also that of education. As with any healthcare methods to motivate them
professional, the basic requirement for an asthma • A knowledge of educational theories and
educator is appropriate knowledge [43]. With principles
special reference to asthma, the educator must • Recognition of maladaptive patterns of behav-
understand the: ior in individuals or families [158]
• Strategies for dealing with non-adherence
• Pathophysiology of asthma • A focus on a variety of health-related behav-
• Methods of diagnosis iors that include adherence to medical
• Spectrum of severity regimens
• Morbidity from asthma • Teaching skills that range from active listen-
• Medications used in treatment ing to interviewing and communication skills
• Side effects of medications and how to mini- [159]
mize them • Good time management and record keeping
• Lead time to effectiveness for the different skills
medications • The ability to establish rapport with the person
• Selection, use, and care of the various asthma with asthma and the family
medication devices • Creation and maintenance of a suitable learn-
• Methods of monitoring and assessment ing environment that is encouraging, support-
• Goals of asthma therapy ive, and non-judgmental
• Rationale behind various treatment options • Devising an individualized education program
• Psychology of chronically ill individuals to meet the needs of the person with asthma
• Reasons underlying noncompliance or and adapting it as needed to meet changing
non-adherence needs
• Asthma triggers • Preparing educational objectives and estab-
• Effect that allergies have on the person with lishing instructional goals
asthma and methods for coping with, as well • Preparing suitable educational materials
as avoiding, allergen exposure • Supervising the practice and application of the
• Environmental controls required for control of necessary skills
the disease and how to implement them in a • Providing education in a variety of settings
practical, low-cost way • Evaluating the effectiveness of teaching
• Evaluating the outcomes in terms of the per-
And, as mentioned earlier, the educator is also spective of the person as related to quality
required to know how to educate [156, 157]. This of life
requires: • Providing feedback, reinforcement, individ-
ualization, facilitation, and relevance in edu-
• An assessment of attitudes, beliefs, concerns, cating both those with asthma and
and educational needs of those with asthma in caregiver(s)
dealing with psychosocial, socioeconomic, • Being a mentor to those with asthma and care-
cultural, and age-specific requirements and givers [160]
limitations [134] • Working with a team of healthcare
• A sensitivity and understanding of ethnic and professionals
religious differences
• An awareness of all possible reasons for An essential addition skill is being adept at
non-adherence facilitating online learning.
The function of the educator [37, 145] is the most confident “student” will require support
therefore to assess the person with asthma, assist from time to time, the goal of guided self-
in defining needs, plan the sequence of learning, management is to bring them to the point where
create the conditions conducive to learning, use they no longer need constant help.
effective methods of teaching, provide resource An asthma educator must therefore be credi-
material, and finally evaluate or measure the ble, competent, confident, courteous, compas-
results of learning. The educator who recognizes sionate, and an excellent communicator.
the person with asthma as an individual and who Credibility will be judged by their students, who
provides assistance can markedly and signifi- will expect the most current (and accurate) infor-
cantly reduce the suffering and costs of this mation. But they will not expect their educator to
chronic disease [161]. know everything and will be much more accept-
The implication in this process is that as the ing if the educator frankly admits, when neces-
self-confidence of the person with asthma sary, that the answer to a particular question is
increases, his or her dependency on the educator not known. People with asthma will be even more
will be progressively decreased. In time the per- appreciative if the educator then makes the effort
son with asthma will no longer need the educator. to find the required information.
This then is the goal of guided self-management.
Points to Ponder
1.7.4 Essential Qualities Qualities of an asthma educator

of the Educator
• Credibility
The asthma educator on occasion may be the pri- • Courtesy
mary healthcare provider for those with asthma, • Competence
but more often, another professional will perform • Compassion
this function. In the latter situation, the educator • Confidence
should serve as a liaison between the primary • Communication
healthcare provider and the person with asthma.
In general, when a physician or healthcare pro-
vider is consulted, all too often there are feelings
(on the part of the individuals with asthma) that Competency in asthma education will come
the connection and communication could be from knowledge of asthma coupled with the abil-
improved. The asthma educator hence has a pri- ity to do an individual assessment and devise a
mary task—to explain asthma in ways that can be teaching program based on a particular person’s
understood—this will be welcomed by those with specific needs and concerns. Competency will
asthma. It is the educator’s job to explain their also make itself evident in all dealings with those
asthma, the diagnosis, and the recommended with asthma; in the asthma action plans that the
treatment in terms to which they can relate. educator helps them devise; in the solutions that
Whenever it is necessary to use technical the educator helps them find for their problems;
terms, the educator must always explain them and in the educational methods that are chosen
clearly. They must also help the person with depending on the age, development, and specific
asthma devise an asthma action plan. Then the learning pattern of the person being taught.
educator can help the person follow the plan at Competency will also be reflected in:
every exacerbation until such time as the person
is willing and confident enough to carry it out • The skill used in dealing with those with
without ongoing support from the educator. At asthma and their problems
that point, the educator will have some certainty • The flexibility demonstrated when faced with
that the teaching has been effective. While even unusual situations
• The ability to find creative solutions that would interfere with allaying those fears and
• The methods used to help those with asthma needs, so that the person being taught does not
devise appropriate solutions to problems feel that the educator is rushed and unable to pay
• Techniques used to help them set goals and attention to their concerns. The compassionate
adapt to changing situations educator will see things from the perspective of
• Assessment of outcomes the person with asthma, understand the person’s
• The provision of appropriate feedback to difficulties, help find solutions, and accept their
those with asthma and/or caregivers decisions, however unsatisfactory those deci-
• On-going evaluation of the effectiveness of sions might be.
teaching methods used The educator’s ability to communicate effec-
• Adaptation of teaching methods to meet tively with the person with asthma will manifest
changing goals and needs itself in the choice of teaching aids and in the use
of simple and clear explanations. It will show in
Confidence will show in the selection of what the written instructions provided and the answers
is to be taught, the actual teaching, the tech- given to questions. It will also show in the skill
niques used, and particularly the educator’s with which those with asthma are drawn into the
ability to dispel fears. It will be most evident in teaching process, encouraged to build on what
the type of learning environment that the educa- they already know, and helped to set and achieve
tor provides and in how well-organized the edu- realistic goals.
cator is. The asthma educator is the coach for the team,
Courtesy requires that every person be treated the mentor [159], and the person who helps those
with respect, in a nonjudgmental manner that with asthma learn, experiment, and develop
recognizes cultural and ethnic differences and skills. It is through education and support that
does not discriminate in any way or for any their fears, as they move from diagnosis to accep-
reason. tance to control, can be reduced. This also
Courtesy is also an awareness of potential cul- requires that the asthma educator make the effort
tural conflicts and linguistic barriers. It is the to stay current with recent advances, the newest
result of the educator’s attitude and motivation to medications, and the latest asthma devices. This
provide those with asthma with the opportunity in turn implies a consistent and continual effort to
to participate in their own healthcare. It will show learn [162]. Staying up to date requires time and
in the preparations made and in interdisciplinary effort.
cooperation. It will be revealed in the degree of To the primary healthcare provider, the asthma
acceptance of decisions that may foster self- educator is a member of the team that provides
defeating behaviors—even decisions that (in the asthma education. To the team, the educator is a
opinion of the educator) are likely to lead to fur- colleague. To those with asthma, the educator
ther harm. Acceptance of those decisions is also will be a lifeline.
important in such extreme situations, and those When the educator has built a close relation-
with asthma are more likely to accept advice ship with those with asthma, those persons will
when it is accompanied with a respect for their confide the most intimate details of their lives,
point of view. knowing that that confidence will not be betrayed.
Compassion will be evident in the empathy They will come for help knowing that it will be
displayed towards those with asthma, in the sen- provided. They will be comfortable communicat-
sitivity shown to their feelings, the support and ing with the educator. They will regard the educa-
encouragement provided, and the amount of time tor as a source of information and for help in
spent with them. Given an allotted amount of medical, social, and financial contexts. They will
time, the asthma educator must focus first and depend on, and trust, the educator. The educator
foremost on the person’s fears and needs and be will be their teacher, their confidant, and, above
willing to jettison and adjust planned teaching all, their mentor and guide.
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Lung Structure and Function
2
Contents
2.1 The Respiratory Tract 40
2.2 Parts of the Respiratory Tract 40
2.2.1 Nose 40
2.2.2 Mouth and Pharynx 41
2.2.3 Larynx 41
2.2.4 Tracheobronchial Tree Including Alveoli 41
2.2.5 Histology of the Airways 43
2.2.6 Rib Cage and Diaphragm 44
2.3 The Nervous System and the Lungs 45
2.4 Control of Breathing 46
2.5 Defense Mechanisms of the Lungs 48
2.5.1 Specific Defenses: Immunological Mechanisms 48
2.6 Lung Changes and Pathophysiology of Asthma 50
2.7 Conclusion 54
2.8 Background Reading 54
References 54

40 2 Lung Structure and Function
Key Points
• The Respiratory Tract—From the Nose
to the Tracheobronchial tree
–– Histology of the airways
–– Rib cage and diaphragm
• The nervous system and the lungs
• Control of breathing
• Defense mechanisms of the lungs
–– Specific defenses—Immunological
mechanisms
• Lung changes in asthma and the patho-
physiology of asthma Fig. 2.1 The respiratory system
2.2 Parts of the Respiratory Tract

Chapter Objectives
2.2.1 Nose
After reading this chapter, you should be
able to: This is the normal route for outside air to enter
the body. A septum divides the nose into right
1. List the parts of the respiratory tract, and left nostrils, and posteriorly the nose opens
explain their function, and describe how into the pharynx through two choanae. The front
each is affected by asthma. of the nasal cavity is the nasal vestibule, which
2. Explain the role of allergy in asthma. extends from the face to the nasal valve. It is sup-
ported by cartilage that keeps it open during the
negative pressure of inspiration. The nasal vesti-
bule is lined with skin from which hairs grow.
2.1 The Respiratory Tract These hairs filter inspired air and are the first of
many defense mechanisms that protect the lungs
The respiratory tract, which starts at the nose and from harmful inhaled materials.
lips and continues through the air passages to the The nasal septum itself is not always precisely
alveoli (air sacs), should be considered as one midline and may be deviated to one or the other
unit. See Fig. 2.1. Much of it is contained within side. This can lead to significant narrowing of a
a specific area of the body, the thorax, with the nostril and consequent problems in breathing. On
ribs and diaphragm forming the boundaries. The the side wall of the nasal cavity are three horizon-
heart is also within the thorax, and blood vessels tal downward-sloping, scroll-shaped bones point-
to the lung come from both the right side (through ing towards the septum. These are the conchae
the pulmonary artery) and left side (the bronchial that create three passages—the inferior, middle,
artery, via aorta) of the heart. The lining of the and superior meatus. The conchae are also called
respiratory tract, from the nose all the way to the turbinates since they help increase turbulence
alveoli, forms an interface between the outside within the nasal cavity. They significantly
world and the human body. Thus the detailed increase the surface area of the nasal cavity and
structures of the surface lining of the respiratory allow greater contact between the unfiltered
tract, both in the nose or in the lower airway, inspired air (which has not yet been humidified)
share many common features. Diseases affecting and the nasal mucosa.
this lining, such as allergic rhinitis (hay fever) of Four paired sinuses—frontal, maxillary, sphe-
the nose, have much in common with asthma. noid, and ethmoid—drain into the nasal cavity
under the nasal turbinates. When healthy, the immediately in front of it. Behind, and to some
sinuses contain air, but infection may occur extent on each side of the larynx, is the esopha-
within them. When there is an allergic disease of gus (gullet) which leads to the abdomen.
the nose, swelling of the mucosa may narrow the The diaphragm is the major muscle of respira-
opening from the sinuses into the nasal cavity tion. It is controlled by the phrenic nerve, while
known as the ostiomeatal complex and make the vocal cords are controlled by the laryngeal
drainage of normal mucus difficult. The mucus nerves. During breathing, the body automatically
then accumulates in the sinuses. coordinates the diaphragm’s movement with the
The nose performs three functions: filtration, opening and closing of the vocal cords. The vocal
humidification, and heat exchange. The inner cords have to be closed when eating, so that food
shape of the nose promotes air turbulence. The can pass smoothly behind the larynx, into the
turbulence presents a greater volume of air to the esophagus, and onto the stomach. When breath-
mucosal lining of the nose than would a “smooth” ing, though, the vocal cords must be open. When
inhalation, enabling the mucosal lining to trap the vocal cords are irritated, for example, with
many dust particles. The mucosal lining thus hin- acid coming back up from the stomach, they will
ders the progress of dust into the lower airways. close in spasm, and again this is protection
Turbulence within the nose increases with accel- against such substances passing through the lar-
erated or rapid breathing. The nose’s ability to ynx into the lungs.
filter and absorb particles varies with individuals
and tends to be lower in children.
2.2.4 Tracheobronchial Tree
Including Alveoli
2.2.2 Mouth and Pharynx
The first part of the tracheobronchial tree is the
The mouth and pharynx contain the tongue, pal- trachea. The trachea is partly outside the chest
ate, and teeth. This is not the usual route for and partly inside. It starts immediately below the
breathing, as air passing through the mouth does vocal folds and continues to the carina when it
not get the same degree of filtering as air passing divides into the right and left main stem bronchi.
through the nose. During vigorous exercise, The trachea is not round in cross section, but
when large breaths are taken, air is taken in varies in shape. Most of the time, it is U-shaped,
through the mouth. Air also passes through the but where blood vessels leaving the heart cross
mouth whenever the nose is blocked. Common the front of the trachea, it may be slightly flat-
causes for blockage include allergic rhinitis on a tened. The main supports for the trachea are
long-term basis or a common head cold in the horseshoe-shaped cartilaginous structures that
short-term. are open at the back and vary in number between
8 and 20. Without the cartilage, the trachea would
readily collapse during inspiration or expiration,
2.2.3 Larynx thereby preventing any movement of air. Also, if
the cartilage were not present, cough would
The larynx or voice box can be felt under the become totally ineffective, as the trachea would
skin—as thyroid cartilage, commonly called readily collapse during coughing.
Adam’s apple. The larynx contains the vocal The two main stem bronchi branch off from
folds (vocal cords) which open and close during the trachea at slightly different angles at the
inspiration and expiration. The width of the open- carina. The right main stem bronchus varies just
ing controls the amount of air that enters the tra- a little, about 20°, from a straight line, and the
chea. Vibration of the vocal folds produces sound. right upper lobe bronchus branches off immedi-
The larynx is given some protection by a carti- ately after the right main stem bronchus leaves
laginous structure, the epiglottis, which sits the trachea. Further down the right side is the
bronchus intermedius, after which the middle in the center is at highest velocity. Airways are
lobe bronchus moves off anteriorly, while the rest asymmetrical and irregular, and this changes the
of the right main stem bronchus proceeds to the pattern of flow to one of turbulence, which is cha-
right lower lobe. otic and has many swirling currents. In this area,
The opening to the middle lobe (which exists turbulence may move the air towards the airway
only on the right) is slightly elliptical and is eas- wall as well as towards the alveoli or the mouth.
ily plugged by secretions. When this occurs, the If the airways are generally irregular or partially
middle lobe can collapse as air in the lobe is obstructed, then respiration is noisy and an
absorbed, a condition known as atelectasis. The increased pressure is required to move the turbu-
left bronchus at the carina is set at an angle of lent air. The time it takes for air to flow from any
almost 45° from the straight and divides into one alveolus to the mouth varies because of the
branches that go to the lower lobe and to the asymmetry in the airways and the mixture of tur-
upper lobe. There are thus five main lobes arising bulent and laminar flow encountered by the gas
from these bronchi, three on the right (upper, molecules.
middle, and lower) and two on the left (upper and The alveoli are part of the gas exchange area.
lower). Each lobe forms a unit in terms of airway The terminal respiratory unit, consisting of a ter-
supply and blood supply. On both sides, the upper minal bronchiole, alveolar duct, alveolar sac, and
lobe is not only higher than the lower lobe but alveoli, is called an acinus. The numbers of alve-
tends to be in front, with the lower lobe behind. oli increase through adolescence until there are
The middle lobe is situated to the front and to the about 300 million in an adult. Gas exchange
right side. Each of the main stem bronchi also has occurs at the surface of the alveoli, and the total
cartilage supporting the wall. surface area available for this gas exchange has
Within the lobes, the airways keep dividing, been calculated as being between 50 and 100
and there are up to 23 subdivisions or generations square meters.
of airway. No gas exchange takes place in the air- Gas exchange takes place at the alveolar capil-
ways. The bronchi divide into segmental and sub- lary membrane, through type I and type II cells.
segmental bronchi. After the third generation of Type I cells comprise most of the surface area.
airway divisions, the bronchi are within the lung Type II cells are shorter and more complex, pro-
parenchyma, which is the functional part of the ducing surfactant. Capillaries are embedded in
lung. Within the parenchyma, each airway moves the walls of the alveoli. Gas exchange takes
on through different generations until it reaches place, with oxygen moving from the alveoli into
the alveoli, but each airway is also part of the a capillary which eventually goes to the left
supporting structure for other airways. All of the atrium and thence to the body via the left ventri-
airways, from the carina to the alveoli, are known cle and aorta. Carbon dioxide is removed from
as conducting airways. In contrast to alveoli, they capillaries as they enter the alveoli, these capil-
do not increase in number throughout childhood. laries being the smallest vessels arising from the
The smallest airways (bronchioles) lead to pulmonary artery.
alveolar ducts and then to the alveoli themselves. Thus, the movement of blood, both from and
The small bronchioles have no cartilage. to the heart via the capillaries of the alveoli, is
By the time air reaches the respiratory unit, it key to respiration. Blood returning from all parts
is already at body temperature and fully (100%) of the body (apart from the lung, with one small
saturated with water. The process of saturation exception) does so via the inferior and superior
starts the instant air enters the nose and continues venae cavae to the right atrium. The blood passes
until complete saturation has been achieved by through a valve into the right ventricle and is then
the time it reaches the alveoli. Airflow is gener- pumped via a large artery (the pulmonary artery)
ally laminar (layered), with discrete streamlines to the lungs. The pulmonary arteries run along-
or layers moving at different speeds. The layer of side the airways, branching as the airways branch,
air next to the airway wall is stationary, while air becoming progressively smaller. They become
arterioles, and then capillaries, the smallest blood thelium, at first without, and then with, cilia.
vessels. Oxygen is transferred to the capillaries Cilia are small hair-like structures that move
from the alveoli. The capillaries then join together mucus along by beating in a coordinated manner.
and run alongside the arteries and the airways, Cilia are an important component of the defense
but they are now the pulmonary veins. Eventually mechanism of the lung. Underneath the epithe-
the right and left pulmonary veins flow into the lium is an extensive capillary network with blood
left atrium of the heart. Blood then flows through vessels lying deeper in the mucosa. These vessels
a valve into the left ventricle of the heart. It is can widen or narrow, thereby changing the
pumped into the aorta and then around the body, amount of blood underneath the lining of the
this time with oxygen which it has picked up nose and providing a way for air passing through
from the lungs. the nose to be warmed.
The lungs have an additional blood supply The structure of the lower airway wall is much
from the aorta via the bronchial arteries. These more complex than that of the nose. Epithelium
supply the airway walls and supporting tissue of lines the airways and contains cells that secrete
the lung—from the major bronchi down to respi- mucus. There are also cilia on the epithelium
ratory bronchioles—with the oxygen the lung throughout most of the bronchi and bronchioles.
requires to do its work. Once oxygen has been Immediately below the epithelium is a basement
removed from the blood in the bronchial arteries membrane below which are layers containing
to meet the needs of the lungs, the blood circu- smooth muscle, elastic fibers, blood vessels, and
lates toward the heart. Some of this blood drains nerves. Below this is a layer of cells, the submu-
back via the bronchial veins into the right atrium. cosa, which again contains glands with mucus.
However some of the blood from the bronchial Finally, there is the supporting tissue that sur-
arteries drains directly into the pulmonary veins, rounds the airways and blood vessels, called
thus diluting the oxygen-rich blood coming from adventitia, although this particular sheath does
the capillaries of the alveoli with a small amount not go beyond the bronchioles. See Fig. 2.2.
of oxygen-poor blood. The epithelium initially contains cilia and
goblet cells, but further down the airway, the lay-
ers become thinner and flatter and near the alve-
2.2.5 Histology of the Airways oli lose the cilia. Cartilage disappears at the same
time, and goblet cells become fewer as the air
Histology describes the fine structure of the air- passage moves down towards the alveoli. The
ways, which may be seen under a microscope layer of cilia is covered with mucus secreted by a
using special stains. The nose is lined with epi- variety of glands, and the movement of these cilia
Fig. 2.2 Functional anatomy of the bronchial mucosa

is coordinated. This movement, which allows the through the diaphragm. Twelve pairs of ribs make
layer of secretions to move from the most periph- up the front, back, and sides of the chest wall.
eral airways towards the pharynx, is called the The ribs are hinged at the vertebrae in the back
“ciliary escalator.” and are connected by muscle. Some of the ribs
Mucus production by the airway is important are joined to cartilage in the front.
both in health and disease. Mucus is produced by The chest wall with the ribs forms an ellipse
the goblet cells in the surface epithelium, by rather than a circle. It has its greatest diameter at
serous cells in the surface epithelium, by Clara the level of the 8th or 9th rib; it narrows slightly
cells in the bronchioles, and by serous and mucus below that level until it reaches the abdomen. The
cells in the submucosal gland. Mucus itself is a chest wall narrows rather more above the 9th rib
mixture of substances—about 95% water, 1% towards the level of the thoracic inlet and the
salts, and between 1% and 3% proteins, mainly boundary of the first rib.
glycoprotein and mucins. The bottom boundary of the rib cage is the
Mucins are peptides of high molecular weight diaphragm. This is a very large and powerful
with sugar side chains, and also within the mucus muscle, with right and left parts. It consists of
are some non-mucus proteins such as albumen both muscle and a central tendon. Its nerve sup-
and immunoglobulin. The function of mucus in ply is the phrenic nerve, which starts in the neck
health is to clear inhaled particles and debris and at the level of the fifth cervical nerve and then
to form a barrier against bacteria and viruses. If runs down through the neck, through the chest
mucus is overproduced or becomes too thick, it close to the heart until it reaches the diaphragm.
may participate in disease processes such as In normal quiet breathing, inspiration depends
asthma, and this will be discussed in more detail on contraction of the diaphragm. When it con-
later. tracts, the diaphragm pulls around the rib margin
Smooth muscle is also important for airway and on the central tendon and thus flattens itself.
function, both in health and disease. The exact It pushes down on the abdomen and pushes the
location of the smooth muscle varies with the abdominal wall outwards. At the same time, the
size of the airways. In the trachea and large bron- ribs move and become more horizontal, causing
chi, a band of muscles bridges the opening of the the rib cage to become larger and rise slightly.
reversed U-shaped cartilage. In the next largest Other muscles of breathing, called the acces-
airways, the muscle bundle connects the tips of sory muscles, also exist. The most important of
the cartilage. As the airway size decreases, the these is the intercostal muscles that lie between
muscle shifts along the inside of the cartilage the ribs. See Fig. 2.3. In quiet breathing the inter-
until it is detached completely and forms a sepa-
rate layer between the cartilage and the
epithelium.
In the medium and small bronchi, when the
smooth muscle contracts, it causes a reduction in
both the thickness and the length of the bronchus.
This increases the rigidity of the airway.
Smooth muscle receives nerves both from the
sympathetic (excitatory) and the non-adrenergic
(inhibitory) pathways.
2.2.6 Rib Cage and Diaphragm
The lungs are enclosed within what is effectively

a cage, which has openings towards the neck and Fig. 2.3 Primary muscles of ventilation
2.3 The Nervous System and the Lungs 45
costal muscles are used minimally. As breathing is sent to and processed by the brain, and the
increases in depth and frequency, the intercostal return “instruction” is then delivered via
muscles are used more, and their activity can be somatic nerves.
observed by watching a person breathe. Other The main somatic nerve for breathing is the
accessory muscles reside in the neck, and again, phrenic nerve that emerges from the spinal cord
when respiration increases in depth, these mus- at cervical levels 3–5. This passes through the
cles are used to lift the ribcage up and increase chest, close to the heart, and then divides into
the volume of air that can be inspired. numerous small branches when it reaches the
Expiration is generally a passive movement diaphragm. The intercostal nerves are nerves that
that is a result of the recoil of the various muscles come from the spinal cord directly to the various
and the ribs, but there may also be some active intercostal muscles. The movements of these
movement of some of the intercostal muscles to muscles are coordinated, along with the main
empty the lungs at the end of each breath. nerve to the vocal cord, which is the recurrent
laryngeal nerve. This nerve is a branch of the
vagus nerve. The right recurrent laryngeal nerve
2.3 he Nervous System
T enters the chest, loops around the aorta, and then
and the Lungs returns to the larynx.
The autonomic nerve fibers enter the lung at
The nervous system has two parts: somatic and the hilum (or opening) and run along the same
autonomic. The former deals with skeletal mus- general course that has already been described
cle and with nerves coming from the central ner- for the airways and blood vessels. The autonomic
vous system directly to the muscle. A synapse system is divided into sympathetic and parasym-
connects the nerve ending and the muscle. Myelin pathetic components. See Fig. 2.4. There is a
surrounds the nerve, and acetylcholine is the neu- third system, a non-adrenergic, non-cholinergic
rotransmitter substance. system, whose functions are not fully
The autonomic nervous system deals with the understood.
smooth muscle in the bronchial wall (and also The parasympathetic fibers go to airway
with cardiac muscle, and the activity of the vari- smooth muscle and also to the mucus glands.
ous glands in the airway). It is nonvoluntary, and They secrete acetylcholine. The activity of the
target tissues may be either stimulated or parasympathetic nerves ensures there is constant,
inhibited. low-level, smooth muscle contraction resulting in
Nerve endings have two neurons in series: a a “tone” to the airways. Unlike skeletal muscle,
preganglionic neuron, which connects the ner- such as the diaphragm, the structure of smooth
vous system to an autonomic ganglion, and a
postganglionic neuron, which goes from the gan-
glion to the target tissue. The preganglionic neu-
ron cell bodies are in the cranial nerves and in the
spinal cord. They have myelin cover; thereafter
there is no myelin cover. The preganglionic neu-
rons release acetylcholine, while the postgangli-
onic neurons release either acetylcholine or
norepinephrine.
When the somatic sensory nerves in the
chest wall sense that the muscles are being
stretched, they inhibit expansion of the chest
wall and then initiate contraction. A neural
message about the expansion of the chest wall Fig. 2.4 Subdivision of the central nervous system
muscle permits prolonged contraction. Increased Table 2.1 Action of epinephrine

activity of the parasympathetic nerve leads to Location of effect Receptors Effect
more intense contraction of the smooth muscle, Mast cells Beta-2 Inhibits
secretions
called bronchospasm. Parasympathetic nerve
Bronchial smooth Beta-2 Relaxes
activity also increases the production of mucus muscle
glycoproteins. Heart Beta-2 Increases rate
Nerves in the sympathetic nervous system are and force
called adrenergic fibers. They secrete norepi- GI tract Alpha and Decreases
nephrine. Stimulation of the adrenergic receptors beta-2 motility
Blood vessels of Alpha-1 Causes
in the airway causes the smooth muscle to relax. skin and gut constriction
This is called bronchial dilation or Blood vessels of Beta-2 Dilates
bronchodilation. skeletal muscle
The receptors themselves are, for the most Eye Alpha Constricts pupils
part, specialized areas of cell surfaces that inter-
act with various natural compounds of the body
and also with drugs. The interaction of the trans- Beta-2 receptors are also responsible for dila-
mitter substance or drug with the receptor pre- tion of blood vessels and relaxation of the uterus.
cipitates a chain of biochemical events. They are responsible for tremor in the skeletal
Agonists regulate receptors and can bind to muscles of the extremities. They act metaboli-
receptors. Some agonists, known as antagonists, cally and lead to an increase in serum concentra-
can prevent other agonists from attaching them- tion of glucose. See Table 2.1.
selves to receptors and thus block their function.
This antagonistic blocking action can be partial
or complete, reversible or irreversible. The 2.4 Control of Breathing
receptors mentioned earlier are very important
in asthma and relevant to medication use. The fundamental function of respiration is to
The transmitter that affects the sympathetic supply adequate oxygen to support normal
nervous system is norepinephrine or epinephrine. human activity and to ensure the removal and
The receptors involved are called adrenergic excretion of carbon dioxide.
receptors. There are two general types, named The lungs work very efficiently under the
alpha and beta, with the numbers and types varying workloads that occur when individuals
varying according to the tissues in which they are are in good health. Blood levels of oxygen and
found. carbon dioxide are maintained within narrow and
Adrenergic receptors are important in asthma. consistent limits. The components that play an
The main ones are the beta-adrenergic receptors important role in the control of breathing are
that are divided into two groups, beta-1 and beta- described as controllers, effectors, and sensors.
2. Beta-1 receptors are found primarily in the The controllers are the:
heart and cause tachycardia (rapid heartbeat)
when stimulated. Beta-2 receptors are found pri- • Cerebral cortex, which permits some volun-
marily in the airways. When stimulated, both tary control over breathing
beta-1 and beta-2 receptors cause: • Brain stem, which provides automatic control
• Spinal cord
• Smooth muscle relaxation
• Inhibition of mediator release by mast cells The effectors are the nerves leading to the mus-
and basophils cles of respiration and to the lungs. The sensors are
• Reduction in mucosal edema nerves in the lungs, chest wall, and receptors (che-
• Increased mucus clearance moreceptors present in the carotid body) which
• Decreased airway reactivity measure and respond to blood gases in the body.
2.4 Control of Breathing 47
Breathing is regulated from moment to in both the rate and depth of breathing. This also
moment. It varies with exercise, sleep, and dis- occurs in anxiety.
ease. Breathing when a person is asleep is very Central and peripheral chemoreceptors also
different from that when awake. When asleep, play a role in the control of respiration. The cen-
breathing also varies with the different stages of tral chemoreceptors are nerve cells in the medulla
sleep. For example, during REM (rapid eye (a subdivision of the brain stem). These nerve
movement) sleep, breathing is irregular, with cells are very sensitive to changes in pH (hydro-
brief periods of apnea lasting between 15 and 20 gen ions), which reflect changes in CO2 levels.
seconds. The central chemoreceptors are surrounded by
When oxygen levels fall, a condition called cerebrospinal fluid which is separated from the
hypoxemia occurs. An acute shortage of oxygen blood by a membrane called the blood-brain bar-
causes extreme distress. Various body mecha- rier. When CO2 accumulates in the body, it passes
nisms are activated, and they work to restore oxy- rapidly through this barrier into the cerebrospinal
gen levels to normal. When the shortage of fluid and forms hydrogen ions. The central che-
oxygen is long term, as may occur in disease, moreceptors then sense the increase in acidity,
there may be some adaptation, leading to less reflexively increase the rate and depth of breath-
distress. ing, and are thus the ongoing minute-to-minute
Because the body strives to maintain normal controller of ventilation.
blood gas levels, exercise causes an increase in Peripheral chemoreceptors are located in very
the rate and volume of ventilation. If the exer- small structures in the arteries called the carotid
cise is either very hard or prolonged, blood oxy- and aortic bodies. There is a carotid body on each
gen levels may drop. At the same time, carbon side in the common carotid arteries, while the
dioxide may increase, and this leads to a small aortic bodies are in the arch of the aorta. Impulses
fall in pH and therefore an increase in blood from these receptors travel to the respiratory con-
acidity. As carbon dioxide (CO2) accumulates, trol center in the medulla. Whereas the central
respiration automatically becomes more rapid chemoreceptors respond rapidly to changes in
and deep, causing CO2 levels in the blood to be CO2 and hydrogen ions but not to oxygen, the
lowered. The various sensory reflexes provide peripheral chemoreceptors are the oxygen sen-
some control over the depth of breathing and the sors as they respond to changes in oxygen (O2)
amount of chest expansion. These reflexes are levels in the blood.
affected by other factors such as the air Stretch receptors in the lung and chest wall,
temperature. while important in respiration, have a lesser
impact than the chemoreceptors. Within the lung
there are several receptors, all of which use the
Points to Ponder vagus nerve to send information to the central
Main regulators of ventilation nervous system. Slow-adapting stretch receptors
exist within the smooth muscle of the airway, and
• Carbon dioxide these are stimulated by a deep breath. A deep
• Reflexes breath will inhibit parasympathetic activity, and
• Psychogenic factors, since part of venti- this, as mentioned earlier, leads to smooth muscle
lation is under voluntary control relaxation and bronchial dilation. Rapid-adapting
• Other factors, such as temperature receptors, called the irritant receptors, also exist,
in the larynx, trachea, and main stem bronchi.
When stimulated by foreign substances, they act
very quickly, and this, in turn, leads to a number
Ventilation is mainly automatic, but it is also of protective responses: narrowing of the larynx,
voluntary and may be influenced by psychogenic cough, deep breathing, mucus secretion, and
factors. In panic, for example, there is an increase bronchial constriction.
Stretch receptors are also contained in the 2.5 Defense Mechanisms

intercostal muscle and the diaphragm. As part of of the Lungs
the somatic system, they pass impulses to the spi-
nal cord. They are important in terminating The lungs offer multilayer in-depth defense
inspiration. against airborne particles and other potential irri-
Receptors called C-fibers are located in the tants, and some of the reflexes involved have
lung parenchyma, conducting airways, and pul- already been described. Other defenses exist too.
monary blood vessels. C-fibers seem to be They include:
involved in the bronchial constriction that occurs,
for example, after breathing cold air, which cools • The physical structure of the lungs
the airway, or after exercise, which also cools the • The physical structure of the airways
airway. • Non-specific defense mechanisms such as
Based on the physiological information pro- cilia, cough, and mucus
vided so far, we can now make a preliminary • Specific immunological mechanisms
examination of changes that occur to airway
diameter with breathing and of factors that may Particles are prevented from reaching the
affect airway resistance. This section will deal lower airway by the normal filtering that occurs
only with the airways inside the thorax. in the nose or throat, and these particles may
Individual airways proceed through more than sometimes stimulate a sneeze. Particles that
20 divisions, narrowing after each division. reach the vocal cords will stimulate their abrupt
Although the individual air passages at the end of closure, an effective but uncomfortable protec-
these divisions are very small, the total diameter tive mechanism. If they manage to get past the
of all of the small airways taken together is vocal cords, they will stimulate irritant recep-
greater than the total diameter of the larger air- tors, leading to increased production of mucus
ways. Thus, although there may be high resis- that may engulf the particles, following which
tance in an individual small airway, overall ciliary activity will move them towards the
resistance is lower in the peripheral airways than throat. It may also be enough to stimulate an
in the central airways. Resistance is affected by explosive cough.
the size of the airway, the amount and activity of Cellular defenses include the phagocytic
elastic tissue, the tone of the smooth muscle, and cells that incorporate particles (including bacte-
also the recoil pressure as a person breathes in ria and viruses) and then engulf and kill them.
and out. Smooth muscle tone is affected by auto- Phagocytic cells include macrophages, and
nomic nervous system activity, which is in turn these mechanisms are also supplemented by a
affected by O2 and CO receptors. number of biochemical factors. These are
In quiet breathing, the pressure in the airway described next.
is less than the pressure in the supporting tissue
around the airway, leading to some compression
of the airway on expiration. When the rate of 2.5.1 Specific Defenses:
breathing increases, and when expiration is Immunological Mechanisms
forced to empty the lungs, a higher pressure is
generated, and the intrathoracic airway is com- Many of the lung’s defenses lie in immunological
pressed further. Although effort is initially impor- mechanisms that are latent until activated by
tant in this compression, at higher pressures the exposure to foreign material. The stimuli and
compression of the airway becomes independent responses associated with each mechanism may
of effort. This is particularly true at high lung vol- be very specific. See Fig. 2.5.
umes, that is, at the start of, rather than at the end For example, an antigen produces an immune
of, expiration. response in many different ways:
2.5 Defense Mechanisms of the Lungs 49
Fig. 2.5 Process of antibody formation following exposure to a pathogen
• The body clearly differentiates the antigen Type 1 IgE-mediated allergic reactions are the
from a non-antigen. most important in asthma and will be discussed in
• The antigen is taken up by cells called den- detail. Under the influence of interleukin 12 (Il-
dritic cells and pulmonary macrophages, 12) secreted by macrophages, so-called naïve or
which process and deliver the antigen to reac- immature T helper cells differentiate or develop
tive lymphocytes, which differentiate into into so-called Th1 cells. The Th1 cells secrete a
cells known as T or B cells. cytokine known as interferon gamma (IFNy).
• Lymphocytes have an effective response that IFNy inhibits production of IgE antibodies by B
includes synthesis and release of antibodies cells, and this is referred to as the nonatopic pro-
by B cells, or production of potent soluble file. On the other hand, other naïve T helper cells,
products such as cytokines by T cells . under the influence of interleukin 4 (Il-4) from T
cells, differentiate into Th2 cells. Th2 cells secrete
Antibodies formed by B cells are of five differ- Il-4 and Il-13, which in turn influence B cells to
ent classes: IgG, IgA, IgM, IgD, and IgE. These produce IgE antibodies. This is the atopic profile.
differ in their structures and biological properties. In the IgE allergic pathway, antigen-presenting
The IgG antibodies represent about 80% of the cells, both dendritic or macrophages, process
total immunoglobulin family and have primarily a antigen and deliver it to the uncommitted naïve T
protective function against bacteria and certain helper cells which stimulate B cells according to
viruses. IgA antibodies are found predominantly the above paradigm. Then B cells develop in the
in respiratory tract secretions where they provide plasma cells which are the end-stage cells that
immunity on mucosal surfaces. IgE antibodies, actually produce the IgE antibodies.
which are present in the body in exquisitely small Once produced locally in the tissues of the
numbers, have no protective function as far as is respiratory tract, such as the nasal mucosa, the
known, but cause allergic diseases including hay IgE antibodies spill over into the circulation and
fever (allergic rhinitis), many cases of asthma, “home in” onto tissue mast cells and circulating
anaphylaxis (a life-threatening allergic reaction), basophils, binding to the IgE receptors on the
and a variety of other allergic disorders. surface of these target cells. These cells are now
About 20% of the human population has a “sensitized.”
genetically determined predisposition to produce Upon exposure to an antigen (allergen), such
IgE antibodies against substances found in the as ragweed, which stimulated the formation of
environment, such as pollen, dust mites, and the IgE antibodies to begin with, bridging of two
other irritants. These “irritants,” however, do not adjacent cell-bound IgE antibodies occurs. This
bother the other 80%. Individuals who form IgE leads to a series of biochemical reactions which
antibodies are known as atopic. The mechanism culminate in the release of chemical mediators,
by which atopic people become sensitized or such as histamine, from preformed granules in
allergic to foreign substances is unknown. the mast cells and basophils. New synthesis and
release of other mediators (such as leukotrienes) ration of the asthma. These responses are
also occur from the mast cells. described in more detail in the next section.
Release mediators are hence responsible for
tissue injury and other signs and symptoms, for
example, of allergic rhinitis or asthma. The reac- 2.6 Lung Changes
tion described above is known as an immediate or and Pathophysiology
early reaction and is depicted in Fig. 2.6. of Asthma
Other mediators that are released attract inflam-
matory cells, such as eosinophils and neutrophils. Eosinophils have long been known to be present
This attraction process is known as chemotaxis. in the lungs of persons with asthma. They can be
Once attracted to the site of the original reaction, seen in sputum, which is coughed up and can be
these inflammatory cells release tissue-destroying stained specifically to detect their presence.
substances such as eosinophil major basic protein. Modern techniques have confirmed this observa-
This secondary reaction, which does not require tion. For example, biopsy of part of the lung via a
exposure to allergen, takes between 2 and 8 hours bronchoscope, or lavage (production of secre-
to develop and is known as the late reaction. tions after instilling saline), confirms the pres-
The late reaction manifests in the lung as ence of a large number of eosinophils in the air
biphasic symptoms and also in the skin and nasal passages of the lungs. The eosinophils, mast
mucosa. In asthma, the late phase reaction occurs cells, and basophils all show increased levels.
in about 50% of persons with asthma, primarily There is a large migration of lymphocytes to the
in those with moderate to severe forms of the dis- airway epithelium. All of these inflammatory
ease. It is often persistent and more difficult to cells produce cytokines, growth factors, and
treat than the initial reaction. mediators such as histamine and leukotrienes.
The biphasic response is clearly observable in They lead to movement of water into the cells
experimental studies. In such studies, only one and swelling of the mucosal lining of the airway.
trigger is used, and careful measurements are Taken together this leads to narrowing of the air-
made over a long time period. In real life, issues way. See Tables 2.2 and 2.3 and Fig. 2.7.
are rarely so simple or clear-cut. Identification
with certainty of triggers that cause a late
response is unusual. Most individuals with Table 2.2 Phases of the allergic response
asthma are exposed to a variety of triggers by Phase 1 Phase 2 Phase 3 Phase 4
day, and thus many individual early and late Ig E Mast cell Mediators Mediators
responses will blend together into overall deterio- produced activated released take effect
Fig. 2.6 The allergic reaction leading to the early phase of the response in asthma
Table 2.3 Effects of mediators in the allergic response The smooth muscle surrounding the airway
Substance Action Effect may constrict in response to a variety of stimuli.
Histamine Constricts Wheeze Some of this constriction will be direct, such as
bronchi Redness (If
when the airway is exposed to very dilute (hypo-
Opens blood widespread leads to
vessels shock) tonic) or concentrated (hypertonic) saline, both
Leaking from Swelling of which will dramatically change the exchange
blood vessels Itch and pain of water between the airway lumen and the air-
Nerve endings Wheeze and cough
way mucosa. Similarly the drying or cooling of
Mucus
production the airway that occurs during severe exercise pro-
Platelet Narrows Wheeze duces airway smooth muscle constriction because
activating airways Redness (If of similar fluid shifts. Some of the action of the
factora Opens blood widespread leads to smooth muscle will be indirect, in response to
vessels shock)
changes to the autonomic nervous system and
Leukotrienesb Narrows Wheeze
airways Swelling perhaps also in response to various irritants such
Leakage from Wheeze and cough as sulfur dioxide or particles inhaled in the air-
blood vessels way. If the mucosa of the airways is damaged, as
Mucus
in infection or in acute asthma, inhalants may
production
Prostaglandin Narrows Wheeze have more direct access to the nerve fibers and
D2 airways may thereby stimulate more severe bronchial
Kallikrein Opens blood Wheeze constriction.
vessels Bronchospasm Mucus plugs are also an important part of the
Released from granules
a
asthma picture and are seen in almost all cases of
Lipid
b
Fig. 2.7 Formation of mast and inflammatory cells that instigate the early and late-phase reaction
individuals who die from asthma. Mucus plugs further consequences, including a reduction in
may also occur in acute severe and in chronic lung elasticity. The result is that the lung becomes
severe asthma. Once mucus accumulates and “stiffer,” and the diaphragm is no longer
forms a plug, it decreases the space available for dome-shaped.
airflow. This narrow airway then exaggerates the When the lungs are hyperinflated with an
effect of the smooth muscle contraction, so that a increased residual volume, the diaphragm will
lesser degree of shortening of the smooth muscle tend to be flat during expiration, and therefore the
is able to close the airway. body will have to work harder to contract the dia-
Airway hyperresponsiveness is one of the phragm and flatten it further with inspiration.
cardinal features of asthma, and it arises from a This will lead to increased diaphragmatic work
combination of all the previously described and some mechanical disadvantage.
effects of inflammation, smooth muscle contrac- There will also be an increase in the “dead
tion, and mucus plugs. It is intensified by cells space” of the lung (that part of the respiratory
sloughed from the surface and also by changes tract that does not participate in gas exchange).
in the lung as a whole. On receipt of a stimulus, Typically, air in the mouth, trachea, large air-
individual changes of inflammation, smooth ways, and a few of the alveoli does not participate
muscle contraction, or mediator production will in gas exchange. When residual volume is
be initiated, or some combination of these fac- increased, the volume of air in the alveoli is
tors. The net result will be narrowing of the increased. Gas exchange still takes place but only
airways. at the alveolar surface. The larger amount of air
The degree of narrowing, and the time frame (dead space) is still moving with each breath but
over which it occurs, will depend on the severity does not contribute to effective oxygen intake by
of the insult or strength of the stimulus. The the body. This contributes to making respiration
response will be greater if there are any p receding more inefficient.
abnormalities such as mild inflammation, some Ventilation becomes very uneven as asthma
smooth muscle contraction, or some production increases in severity. Blood flows through the
of mucus, or two or indeed all three at the same pulmonary arteries to the capillaries, going both
time. Hyperresponsiveness is also seen in the to those parts of the lungs that are ventilated and
normal morning-to-evening variation in airway to those parts that are not. Capillaries in the ven-
caliber, with the caliber being narrower overnight tilated parts of the lung pick up oxygen and
and wider during the day. The variability in return it to the lungs. Blood going to capillaries
asthma is usually considered reversible, but in of those alveoli not ventilated does not pick up
persons with severe asthma, it may be quite oxygen. When these capillaries eventually con-
marked and not easily reversible. Intensive treat- nect to a large vein, the non-oxygenated blood
ment may need to continue for some time before mixes with blood containing a high level of oxy-
lung function improves. gen. This ventilation/perfusion mismatch is
The overall effect of all of these changes is important in asthma as it lowers the overall level
decreased flow rates through the narrower air- of oxygen returning to the heart for distribution
ways. Given the asymmetrical structure of air- to the body.
ways, there will be asymmetrical closure. This As these changes progress and oxygen levels
will be exaggerated with mucus plugs and bron- fall in the blood, there will be an increase in
chial constriction. Therefore some units of the respiratory drive, which increases the rate of
lung will not be able to empty at the end of expi- breathing. This hyperventilation will then lead to
ration. Over time this will lead to a significant a fall in carbon dioxide. The combined changes
number of units being unable to empty and an of slightly low levels of oxygen and carbon diox-
increase in the air remaining in the chest at the ide are seen in the early stages of severe acute
end of expiration. This volume of air remaining is asthma. Inflammation is probably the most
called the residual volume. In turn, this leads to important underlying pathological feature of
asthma, and chronic inflammation will cause tis- glycoprotein, proteoglycans, and other sub-
sue injury with subsequent changes in structure. stances. Investigations to date point to the small
These longer-term changes are referred to as airways (2–6 microns) as the major site of these
“remodeling.” abnormalities in most individuals with asthma.
The changes wrought by remodeling are not a There are changes in epithelial cells with shed-
new discovery but have received recent attention ding of some cells, loss of ciliated cells, and
with the increasing recognition that not all per- hyperplasia of goblet cells. Airway epithelial pro-
sons with asthma have well-marked reversibility. liferation may be another contributor to airway
Remodeling affects the airway wall, smooth wall thickening. In summary, changes occur
muscle, mucus-producing cells, the subepithelial because of ongoing inflammation, injury, and
layers, production of myofibroblast, changes in repair.
the blood vessels, and possible changes in the The sum total of remodeling is that the airway
matrix composition. Remodeling seems to affect responds poorly to treatment. It has difficulty in
a subgroup of those people with asthma with air- reverting to normal, and there is a chronic
flow obstruction that is at best only partially increase in the work of breathing. Aggressive and
reversible [1]. meticulous treatment may reduce the impact of
Remodeling of the airways has been remodeling, although the evidence for this is not
described in detail [1]. Its changes include an clear.
increase in the thickness of the airway wall. The prevalence of remodeling can only be
Almost all components of the airway wall are estimated using indirect measures. Much of the
thickened—smooth muscle, connective tissue knowledge described in the preceding paragraphs
and mucus glands—and these changes extend to comes from bronchial biopsies or specimens
the submucosa and adventitial tissues. The pro- taken at autopsy. There are obvious difficulties in
portionate increase in smooth muscle mass is obtaining such specimens on a large scale, or
much greater than the increase in total airway even in a small population, and in doing so
thickness. Some of the increase is due to forma- repeatedly over a number of years. Indirect mea-
tion of additional muscle cells, while some is sures such as computed tomography of airway
chronic thickening of the existing muscles. The wall thickness, positron emission tomography
number of mucus glands increases, and they are scans, or measurement of lung function have also
larger than the mucus glands in non-affected been used.
airways. One longitudinal study, which followed 1037
There is also an increase in collagen immedi- children (born between April 1, 1972, and March
ately below the bronchial epithelium, leading to 31, 1973) for two decades, provides important
subepithelial fibrosis. At one time, this was information on the impact of childhood asthma,
thought to be “basement membrane thickening,” airway hyperreactivity, atopy, sex, and smoking
but it is now known that there are only minor on remodeling [2]. The investigators used the
changes in the basement membrane. ratio of the forced expiratory volume in one sec-
Myofibroblast are specialized cells that increase ond and the functional vital capacity FEV1/FVC,
in tissues undergoing repairs, and these cells are (described in more detail in the next chapter) as a
increased in the submucosa of people with measure of remodeling. A ratio that was low after
asthma. They are a source of interstitial collagen use of a bronchodilator, at age 18 or 26, was used
that may contribute to some of the other abnor- as a marker of airway remodeling. The investiga-
malities. The blood vessels, which travel along- tors justified this measurement on the assumption
side the airways, also have vascular congestion, that structural abnormalities in the airway wall
some increased thickening of the walls, and per- prevent full reversibility. The low ratio was found
haps formation of new vessels. in 4.6% of the population at both 18 and 26 years.
A number of other substances are also depos- This group had low lung function throughout
ited in the airway wall, including collagen, matrix childhood. Low ratios were independently asso-
ciated with male sex and airway hyperrespon- 2.8 Background Reading
siveness but not with smoking or atopy. This
study provides data indicating that airway remod- Thomson NC, Rodger IW, Barnes PJ, editors.
eling begins in childhood and continues into Asthma: basic mechanisms and clinical man-
adult life. agement. Academic; 1998.
This study does not provide evidence that Barnes PJ, Drazen JM, Rennard SI, Thomson
remodeling can be prevented. However, it does NC, editors. Asthma and COPD: basic mecha-
identify a marker of disease (FEV1/FVC) that nisms and clinical management. Elsevier;
educators can review at intervals, say annually, 2009 Mar 19.
for individuals with asthma. Those with low Clark TJH, Godfrey S, Lee TH, Thomson NC. Eds.
FEV1/FVC, particularly if the trend is declining, Asthma, 4th Ed. Arnold, London; 2000.
need extra care to identify the best treatment regi- Beachey W. Respiratory care anatomy & physiol-
men and must be encouraged to adhere to it. This ogy foundations for clinical practice. 563 St
is only one of many cohort studies that add to our Louis, Mo. Elsevier; 2013:159–67.
understanding of changes in the lungs of people
with asthma over time.
References
2.7 Conclusion
1. Shifren A, Witt C, Christie C, Castro
M. Mechanisms of remodeling in asthmatic air-
In conclusion, asthma educators must understand ways. J Allergy. 2012;2012:316049. https://doi.
the lung, its normal structure, and the functions org/10.1155/2012/316049.
underlying lung changes when asthma is present. 2. Rasmussin F, Taylor DR, Flannery EM, Cowan JO,
This chapter has provided the essential medical Green JM, Herbison GP, et al. Risk factors for airway
remodeling in asthma manifested by a low postbron-
background they need. In turn, this understand- chodilator FEV1/Vital capacity ratio. A longitudinal
ing is essential in understanding current population study for childhood to adulthood. Am J
therapeutic approaches and why new approaches Respir Crit Care Med. 2002;165(11):1480–8. https://
are needed. doi.org/10.1164/rccm.2108009.
Measurements of Lung Function
3
Contents
3.1 Overview 57
3.2 L
ung Volumes and Capacities 57
3.2.1 Volumes 58
3.2.1.1 Tidal Volume (VT, Sometimes Shown as TV) 58
3.2.1.2 Inspiratory Reserve Volume (IRV) 58
3.2.1.3 Expiratory Reserve Volume (ERV) 58
3.2.1.4 Residual Volume (RV) 58
3.2.2 Lung Capacities 59
3.2.2.1 Total Lung Capacity (TLC) 59
3.2.2.2 Inspiratory Capacity (IC) 59
3.2.2.3 Functional Residual Capacity (FRC) 59
3.2.2.4 Vital Capacity (VC) 59
3.2.2.5 Forced Vital Capacity (FVC) 59
3.2.2.6 Forced Expiratory Volume in One Second (FEV1) 59
3.2.2.7 Integrating Capacities 59
3.2.3 “Normal” or “Predicted” Values 59
3.3 Spirometry 62
3.3.1 FEV1, FVC, and FEV1/FVC 65
3.3.1.1 Forced Expiratory Flow Maximum (FEFmax) 65
3.3.1.2 Forced Expiratory Flow25-75 (FEF25-75) 66
3.3.1.3 Expiratory Flow200-1200 (FEF200-1200) 66
3.3.2 Flow-Volume Loops 66
3.3.2.1 Volume-Time Curves 67
3.3.2.2 Technical Requirements for Spirometry 69
3.3.2.3 Criteria for Acceptability 69
3.3.3 Bronchodilators in Pulmonary Function Testing 70
3.3.4 A Pulmonary Function Test and Its Interpretation 71
3.4 M
easures of Lung Function 71
3.4.1 Peak Flow Measurement 71
3.4.1.1 Calculating Reversibility 75
3.4.1.2 Diurnal Variation 75
3.4.1.3 Calculating Diurnal Variability 75
3.4.1.4 Consistency in Obtaining PEF Readings 76
3.4.1.5 PEF and Adherence 76

56 3 Measurements of Lung Function
3.4.2 Other Measures of Lung Function 77

3.4.2.1 Fraction of Exhaled Nitric Oxide (FeNO) 77
3.4.2.2 Dilution Techniques: Helium and Nitrogen 78
3.4.2.3 Plethysmography 79
3.5 Bronchial Challenge Testing 80
3.5.1 Methacholine and Histamine Challenge 80
3.5.2 Exercise Testing 81
3.5.3 Inspired Cold Air 83
3.5.4 Ultrasonic Distilled Water 83
3.5.5 Adenosine 5’-Monophosphate (AMP) 83
3.6 Other Testing Methods 83
3.6.1 Bronchoalveolar Lavage (BAL) 83
3.6.2 Induced Sputum 84
3.6.3 Exhaled Breath Condensate (EBC) 84
3.7 Oxygen Saturation 85
3.8 P
ulmonary Function Testing in Infants and Preschool Children 85
3.8.1 Pulmonary Function Testing in Infants 85
3.8.2 Pulmonary Function Testing in Preschool Children 86
3.8.2.1 Forced Oscillation Technique (FOT) 86
3.8.2.2 Interrupter 86
3.9 P
ulmonary Function Testing of Adults Unable to Do Standard
Spirometry 86
3.10 Quality Control 87
3.11 Application 88
References 90
Key Points –– These include exhaled fraction of

• Measurements of lung function allow nitric oxide, dilution techniques,
objective values to be used in under- plethysmography, and exercise test-
standing asthma. ing and challenges.
–– They supplement what those with –– Challenges with inspired cold air,
asthma tell us, but do not replace ultrasonic distilled water, and ade-
individual experience of asthma. nosine 5’-monophosphate (AMP) are
• Understanding of lung function testing used in some situations.
implies a knowledge of the meaning of • Examining cell type and counts and
lung volumes and capacities, spirometric other alveolar substances can help in
values, and interpretation of spirograms. describing the asthma phenotype.
–– The peak flow is less accurate than –– These include bronchial lavage,
spirometry, but can be done fre- induced sputum, and exhaled breath
quently at home, in the workplace condensate.
and at leisure. • Special techniques and tests are needed
–– Oxygen saturation can now be read- in infants and preschool children and
ily measured and is essential in the of those adults unable to do
management of acute asthma. spirometry.
• In severe chronic asthma and in research, • Measurements of lung function are
other tests can expand our understand- only as good as the quality control
ing of asthma. used.
3.2 Lung Volumes and Capacities 57
conducting zone of respiration made up by the

Chapter Objectives nose, trachea, and bronchi. In adults this is about
After reading this chapter, you should be 150 ml. Physiologic or total dead space is equal
able to: to anatomic plus alveolar dead space, the volume
of air in the respiratory bronchioles, alveolar
1. Explain spirometry, FEV1, and PEF and duct, alveolar sac, and alveoli—the respiratory
their use in the diagnosis and control of zone that does not take part in gas exchange.
asthma. Anatomic dead space is fairly constant, while
2. Explain the significance of objective
physiological dead space is commonly increased
lung function measurements. in disease.
3. Identify the technical requirements of Equipment used in lung function testing will
spirometry. have additional dead space, that of the tubing that
4. List the different tests used in measur- connects the person being tested to the device.
ing lung function. This is almost always minimal. It is only relevant
5. Calculate diurnal variability using peak when equipment designed for adults is used in
flow readings. children.
Some measures of lung function (see Fig. 3.1)
are easy and repeatable; some are difficult; and a
few can be conducted only in a research labora-
3.1 Overview tory. Measures of airflow and lung volumes using
spirometry are by far the most useful and repeat-
Asthma and lung function measurements go hand able measurements. Other measurements, such as
in hand—an accurate appraisal of the latter is an resistance (by plethysmography), residual vol-
essential component of the assessment process ume (by dilution techniques or plethysmogra-
when dealing with persons who have asthma and phy), or carbon monoxide diffusion, can be
an important objective addition to other measures helpful in specific situations. All these tests, how-
of disease severity. In people with asthma, health- ever, require the full cooperation of the person
care providers, including physicians, often under- being tested; where this is not available (as, e.g.,
estimate or overestimate the severity of asthma, with children, the elderly, or in those who also
especially on initial assessment. Pulmonary func- have other severe diseases), testing is not possi-
tion tests—which provide an indication of lung ble. New tests under development, such as forced
function—can aid in accurate diagnosis and, con- oscillation or interrupter techniques, may enable
sequently, in the management of asthma [1]. some information to be gathered from such per-
sons [2, 3].
Lung function is assessed by measuring the
3.2 Lung Volumes amount of air in the lungs at various stages of the
and Capacities respiratory cycle. These amounts are converted
into percentages and ratios that a healthcare pro-
When measuring lung function, the focus is on vider can use to make a meaningful assessment.
the effects of breathing on gas exchange. In all Much of the terminology associated with lung
measurements, there are two volumes that must function pertains to volumes [4] in the lung, and
be differentiated, ventilated air that participates an understanding of this terminology is essential
in gas exchange and a smaller volume that does for an understanding of lung function testing.
not participate in gas exchange. This latter vol- Figure 3.1 shows both the basic measures and
ume is called “dead space.” In turn, there are two those that involve the sum of two of more vol-
types of dead space. The anatomical dead space umes, referred to as capacities. While both the
is represented by the volume of air that fills the diagram and the terminology may appear daunt-
Fig. 3.1 Lung volumes

and capacities
ing at first glance, they are in fact extremely logi- 3.2.1.3 Expiratory Reserve Volume
cal and very easily understood. (ERV)
This is the difference between the volume exhaled
with a normal breath and the volume that can be
3.2.1 Volumes exhaled after a forced exhalation.
3.2.1.1 Tidal Volume (VT, Sometimes 3.2.1.4 Residual Volume (RV)

Shown as TV) It is physically impossible for a person to expel
This is the amount of air inhaled and exhaled dur- all the air from the lungs. RV is the amount of air
ing normal breathing. It is typically only 10% of that remains in the lungs even after a “maximum”
the lung’s total capacity. In other words, under forced exhalation. RV is usually about 25% of the
normal conditions, the lungs take in just a frac- total lung capacity. A normal exhalation leaves
tion of the volume that can be inhaled. more air in the lungs—about 40% of total lung
capacity—than a forced exhalation. In long-
3.2.1.2 Inspiratory Reserve Volume standing asthma, the RV may increase. RV is cal-
(IRV) culated as
IRV is the difference between the volume inhaled RV FRC ERV
with a normal breath and the volume that can be
inhaled on maximal inspiration.
3.2 Lung Volumes and Capacities 59
(where FRC is the functional residual capac- 3.2.2.6 Forced Expiratory Volume
ity, that is, the amount of air left in the lungs after in One Second (FEV1)
a normal exhalation. See below for more details.) FEV1 is actually a measurement of volume. It is
described here because it is a subdivision of
FVC. FEV1 is the amount of air expelled in one
3.2.2 Lung Capacities second (the very first second) through forceful
expiration after maximal inspiration.
3.2.2.1 Total Lung Capacity (TLC) In persons who do not have asthma, TLC is
TLC is the volume of air in the lungs after the between 6 and 7 liters for men and 5 and 6 liters
maximum possible inhalation. for women. FRC is between 2 and 3 liters for
both men and women. FVC will be about 4 liters
3.2.2.2 Inspiratory Capacity (IC) for men and 3 liters for women. In persons with
This is the total volume that can be inhaled. It is asthma, FEV1 will be less than 80% of FVC, but
comprised of two components: tidal volume (nor- FVC will be maintained at the normal values
mal breathing) and the inspiratory reserve vol- mentioned above.
ume (IRV), which is the additional amount of air
that can forcefully still be inhaled after a normal 3.2.2.7 Integrating Capacities
breath. Without asthma, TLC is between 6 and 7 liters
IC TV IRV for men and between 5 and 6 liters for women.
FRC is between 2 and 3 liters for both men and
women. FVC will be about 4 liters for men and 3
3.2.2.3 Functional Residual Capacity liters for women. With asthma that is not fully
(FRC) controlled, FEV1 is less than 80% of FVC, but
FRC is the amount of air left in the lungs after a FVC will be maintained at the normal values
normal exhalation. mentioned above.
FRC TLC IC
3.2.3 “Normal” or “Predicted”

3.2.2.4 Vital Capacity (VC) Values
VC is the maximum amount of air that can be
breathed out after breathing in to the maximum Before reviewing the various lung function tests
extent. in common use today, it is necessary to under-
VC TLC RV stand what the “normal” values are and how they
were derived.
The normal or predicted values for the tests
3.2.2.5 Forced Vital Capacity (FVC) described here were derived from specific sam-
This is the amount of air that can be expelled ples within the population. This is done to help
forcefully after a maximal inspiration. FVC is assess whether or not there is an abnormality and
affected by both environment and by occupation. the degree of abnormality in comparison to what
Athletes and individuals in physically demanding are deemed normal values.
occupations will have FVCs that are higher than Cross-sectional studies are typically used to
normal (normal being the predicted values for an develop normal or predicted values from cross-
individual of certain height, age, weight, and sectional data, using a certain segment of the
race). FVC also indicates the degree of lung and population—for example, boys aged 10 or
chest expansion, since it measures the total women aged 40. These persons will have their
amount of air that can be blown out as quickly as pulmonary function tested, and their height,
possible after inhaling as deeply as possible. weight, and ethnic origin recorded. Their health
needs will be established through questionnaires,
examinations, and perhaps X-rays. While smok- cross-sectional studies may be the ones actually
ers past and present will be excluded, it will be in use. Care should hence be taken when using, at
difficult to take into account (or compensate for) the same time, data that has been acquired
unpredictable factors such as brief environmental through both methods.
exposures, passive exposure to smoke, or brief Determination of normal lung function values
illnesses. The values for the whole population for a specific individual is hence not easy. Most
under study will then be analyzed to obtain a laboratories arbitrarily assume that a person has
mean and a standard deviation. abnormal readings if these are less than 80% of
Longitudinal studies, where a population is the predicted values. It would be much more
identified, defined, then followed, and studied at accurate and useful to assume that the lowest 5%
pre-defined intervals for a number of years, may of population values are abnormal, but such an
give more accurate results than cross-sectional approach is overly complex for routine use. On
studies. The values and readings obtained are the other hand, tracking the lung function values
most useful for documenting changes that occur of any one individual over time will provide an
over the years—at times of growth, for example, idea of their “normal.”
or with aging [5, 6]. However, while results from Table 3.1 provides definitions, abbreviations,
longitudinal studies are preferred, those from an overview of the terminology, and the methods
Table 3.1 Measures of pulmonary function

Lung volumes
Four primary volumes do not overlap. They are measured in liters
Abbreviation Name Definition How measured Clinical application
in asthma
VT Tidal volume Volume of gas inspired or Spirometer Limited use
expired during each respiratory
cycle
IRV Inspiratory Maximal amount of gas that can Spirometer None
reserve volume be inspired from the end-
inspiratory position
ERV Expiratory Maximal volume of gas that can Spirometer None
reserve volume be expired from the end
expiratory level
RV Residual Volume of gas remaining in the He dilution, May be useful, but
volume lungs at the end of a maximal plethysmograph generally used in
expiration referral laboratories
Lung volumes
Each includes two or more of the primary volumes, measured in liters
in asthma
VC or FVC Vital capacity Maximal volume of gas that can Spirometer Common, useful
be expelled from the lungs by
forceful effort following a
maximal inspiration (IRV+ VT +
ERV)
TLC Total lung Amount of gas contained in the He dilution, Special situations
capacity lung at the end of a maximal plethysmograph
inspiration
IC Inspiratory Maximal volume of gas that can Spirometer Rarely used
capacity be inspired from the resting
expiratory level (IRV + VT)
FRC Functional Volume of gas remaining in the He dilution, Special situations
residual lungs at resting expiratory level plethysmograph
capacity (RV +ERV)
(continued)
3.3 Spirometry 61
Table 3.1 (continued)
Forced expiratory volumes and flows
in asthma
FEV1 Forced Volume of air exhaled in 1 Spirometer and liters Most useful test in
expiratory second starting from a full both diagnosis and
volume in one inspiration continuing
second assessment
FEF25-75 or Forced Volume of air in mid-flow, that Spirometer and liters Wide range of
MMEF mid-expiratory is, the first 25% and last 25% are values limits
flow “discarded” in the last usefulness. See text
measurement for details
FEFmax or FEF Maximal Maximal flow in forced Spirometer and liters Can be easily and
PEF forced exhalation Peak flow meter (PFM) in frequently
expiratory flow/ liters/min measured. Wide
Spirometer/Can range of normal
be easily and
frequently
measured, wide
range of normal
PEF/Peak
expiratory flow
rate/fastest rate
air leaves lungs
after full
inspiration/Can
be easily and
frequently
measured, wide
range of normal
MEFV Maximal Spirometer with Useful in giving a
expiratory simultaneous visual impression of
flow-volume measurement of flow obstruction, and in
curve differential
diagnosis
Ratios
Abbreviation Name How measured Clinical application in asthma
FEV1/FVC Ratio of FEV1 Spirometer Very useful. Lung size varies considerably,
and FVC mainly due to age, gender, and height, and this
allows partial corrections
Other measures of pulmonary function
Abbreviation Name How measured Unit Clinical application
In asthma
Raw Airway Plethysmography and Cm/H20/liters/sec Special situations
resistance pneumotachograph only
Dco Diffusion Inhaled CO (carbon monoxide) MICO/min/mmHg
capacity is measured in expired air
SaO2 O2 saturation Pulse oximetry None Useful in acute
asthma and
exercise testing
used for assessment and measurement of lung Airflow varies with a number of factors, of
function. It also indicates the practical usage of which the dominant one is height. Hence, as chil-
each measurement. dren grow, airflow increases. In adulthood, pul-
monary function tends to peak between the age of
30 and 35 in men and around 30 in women and
3.3 Spirometry then declines. This change in age is independent
of health. It can be hastened by a number of dis-
Spirometry is a laboratory test that has stood the eases, including asthma, genetic factors, and
test of time. It was invented in 1844 by John adverse exposures, the most important of which
Hutchinson, a British surgeon. He published his is smoking [11].
first paper on the subject in 1846 after he had Differences in pulmonary function also exist
measured 2,130 individuals. He also coined the between ethnic groups, but these are not easy to
phrase “vital capacity” and related it to disease estimate or even to understand [12, 13]. For
[7]. Today, FEV1 and FVC measured with a mod- example, studies have shown that the reference
ern spirometer, either physically or electroni- values for Caucasians can be satisfactorily used
cally, are the most useful measures of lung for American Indians [14]. The National Health
function. and Nutrition Examination Survey (NHANES)
Traditional spirometers are machines that III provides predicted readings for males and
measure inhaled and exhaled volumes of air. females between the ages of 6 and 75 for
They combine mechanical components (which Caucasians, African-Americans, and Mexican
measure volumes of air) and computer software Americans in the USA [15]. However, reference
(which performs the various calculations). In the equations need to be adjusted for different ethnic
best spirometers, the software includes tested and groups, for instance, by 12% for Asian-Americans
reliable predictive algorithms. [16]. It is also not easy to define clearly what is
The technologist enters the necessary data meant by “ethnic group,” and differentiating
(age, gender, height, race, whether or not a between one group and another can be difficult.
smoker), and the software then computes a nor- In addition, although some ethnic differences are
mal predicted value for that individual, given the related to lung size (i.e., to the ratio of trunk
available information. length to total height), part of the ethnic differ-
It should be remembered that a number of fac- ences will also be explained by differences in
tors are not fully considered by the equipment socioeconomic status.
and the predictive equation, including genetic All of these factors are particularly important
characteristics; past and present general health; when considering African-Americans. Ethnic
environmental exposures other than smoking; differences do exist between this group and
present or former occupation; type of residential Caucasians, but even without intermingling
premises with exposure to airborne environmen- between populations, genetic differences are
tal hazards; and socioeconomic status [8, 9]. extremely minute. Much of the difference
The use of spirometry has been revolutionized between Caucasians and African-Americans is
by the availability of fully electronic spirometers. due to the greater incidence of socioeconomic
These can calculate airflow rates in the channel problems in the latter. The same consideration of
into which the person blows using a transducer or genetic difference and socioeconomic difference
by measuring pressure differences in the channel. applies to other apparently “distinct” popula-
These devices are very accurate as they do not tions. The position is even more confused with
have moving parts and hence no resistance errors. individuals who reside in North America but
In essence, the software is the spirometer. As will were born elsewhere.
be discussed later, they are ideal for home moni- Because of the interconnections and com-
toring and detecting trends over time [10]. plexities, the standard used for peak flow meter
3.3 Spirometry 63
readings is the individual’s own personal best

[17]. As will be mentioned later, it is one mea-
surement that depends on the effort expended by
the person with asthma, but there is, unfortu-
nately, no real way to control or assess that
effort.
A successful spirometry test demands a great
deal of cooperation from the person being tested.
For this reason, it can be difficult to perform
when other illnesses are present or the individual
is very young or elderly. In terms of lower age
limits, most pulmonary function laboratories Fig. 3.2 Child performing spirometry
expect that children above the age of 6 will be
able to do the test with minimal guidance, and
they may use the same equipment for them as for
adults. However, if “adult” equipment is used in
children, the dead space may introduce
inaccuracies.
It requires a great deal of effort to obtain
accurate readings from the very young.
Reproducible spirometric results have been
obtained from carefully coached children aged
between 3 and 6 years by technologists trained
and experienced in testing children [18]. However
they require more teaching and more time to
become comfortable with the equipment and to
practice blowing through unattached mouth- Fig. 3.3 Portable digital spirometer. (Spirometer ©
pieces. Special techniques, such as incentive Medical International Research. Used with permission)
games [19], can help bring about success, but
even with these aids, only a minority of children
successfully manage spirometry [20] (Figs. 3.2,
3.3 and 3.4).
Today’s spirometers measure flow and calcu-
late volumes electronically and are very accurate.
Less expensive portable devices are also avail-
able for office use.
Spirometry can be used for [8, 21–23]: Fig. 3.4 Handheld digital spirometer. (Spirometer ©
Diagnosis Medical International Research. Used with permission)
• To evaluate symptoms, signs, or abnormal Monitoring

laboratory test results
• To measure the physiologic effect of disease • To assess response to therapeutic intervention
or disorder • To monitor disease progression
• To screen individuals at risk of having pulmo- • To monitor patients for exacerbations of dis-
nary disease ease and recovery from exacerbations
• To assess preoperative risk • To monitor people for adverse effects of expo-
• To assess prognosis sure to injurious agents
• To watch for adverse reactions to drugs with who can perform “acceptable and reproducible
known pulmonary toxicity measurements”; and “a motivated technologist to
elicit maximum performance from the patient.”
Disability/impairment evaluations At the beginning of the lung function test, the
technologist enters all necessary personal and
• To assess patients as part of a rehabilitation environmental data, such as date of birth, both
program height and weight without shoes, race, smoking
• To assess risks as part of an insurance status, time of day, humidity, air pressure, and
evaluation room temperature [8, 9, 25]. The technologist
• To assess individuals for legal reasons will then coach and encourage the person through
several steps. The following sequence must be
Other evaluations observed. The person must
• For research and clinical trials • Take several normal breaths.

• For epidemiological surveys • Inspire, as deeply as possible, to maximal
• To derive reference equations inspiration.
• For preemployment and lung health monitor- • Place the mouth around the tube connected to
ing for at-risk occupations the spirometer.
• To assess health status before beginning at- • Exhale with maximum effort, blowing as hard
risk physical activities as possible.
• Keep exhaling (“squeezing”) till no more air
In its Expert Panel Report 3, the National can be exhaled.
Asthma Education and Prevention Program • Take a hard, deep breath.
(NAEPP) [17] recommends spirometry both in
initial assessment of asthma and later, after A noseclip is optional. In closed-circuit spi-
symptoms and peak flows have stabilized. It rometers, the individual may take five tidal
also suggests that while a handheld peak flow breaths before taking a maximal inspiration from
meter can be used as a diagnostic tool, the meter, the reservoir and then blowing out rapidly till the
with all its drawbacks, is best employed for end-of-test criteria are met.
monitoring changes in asthma in one individual With the smaller, computerized portable
over time. EPR-3 recommends that spirometry machines, test results are available only after the
be done every 1 to 2 years to monitor and pro- test has been completed; larger laboratory
vide an ongoing assessment of airway function machines tend to provide progressive results in
[17, 24]. real time, as they become available.
Baseline spirometry provides a very accurate The technologist watches the subject and
snapshot of the degree of airway obstruction decides whether the test is acceptable or not. If it
caused by asthma and hence its severity at that is, the technologist obtains a printed report that
specific moment. The likelihood of dying from shows the results in both numerical and graphical
asthma is increased among those who underesti- form. This report is a spirogram.
mate their personal degree of airway obstruction Two graphs are usually available, and both
[23]. Hence routine pulmonary function testing should be requested:
should be a part of both the assessment and moni-
toring of acute asthma. It should also be used on • The Flow-Volume Loop
a periodic basis to assess lung function in all • The Volume-Time Graph.
people with asthma [1, 17].
Ruppel and Enright [24] point out that accu- Spirometry measurements of lung volumes
rate results depend on three factors: having a spi- are expressed in liters or milliliters at normal
rometer that is accurate and precise; a person body temperature (37° C), and ambient pressure
3.3 Spirometry 65
and saturated with water vapor [4]. The spirome- Table 3.2 Pulmonary function in asthma
try readings most frequently requested for a diag- FEV1 ↓ TLC ↑
nosis of asthma are listed and explained next. PEF ↓ RV ↑
3.3.1 FEV1, FVC, and FEV1/FVC

• A healthy adult will exhale about 83% of the
The FEV1, FVC, and the ratio FEV1/FVC ratio FVC in the first second, 94% in 2 seconds, and
should be considered together and are the most about 97% in the third second [27]. In asthma,
important measurements in both initial and con- these volumes are all reduced.
tinued assessment of asthma. • For people without lung disease, FEV1 is
The concept of FEV1or “degree of narrowing greater than 3.0 liters for men and greater than
of air passages” is readily understood by most 2.0 liters for women [28]. However, any value
people with asthma. The ratio FEV1/FVC is must take into consideration the age (age
always a fraction (less than 1.0) and is a useful causes a reduction in FEV1 due to decreased
crosscheck on the accuracy of FEV1 normal elastic recoil), ethnicity [23], and whether the
values. person smokes tobacco. Smokers often have
FEV1values require careful scrutiny. An FEV1 airway obstruction, and FEV1 values may well
of 100%, while within the predetermined normal be about 15% lower than nonsmokers, if they
limits for FEV1, may still indicate obstruction. In feel well [26].
this example, if the FVC is 130, then the FEV1/ • In asthma FEV1will be reduced when there is
FVC ratio is 100/130, which is 0.77, or 77% airway obstruction, but FVC is maintained
when expressed as a percentage. unless the asthma is particularly severe. (There
Because it is a ratio, FEV1/FVC provides an may be difficulties in exhaling due to nar-
automatic correction for lung volume. No “nor- rowed airways.) Typically, an FEV1 of 80% or
mal” or predicted values exist for the FEV1/ less is considered indicative of airway
FVC. Further, the American Thoracic Society obstruction.
(ATS) has not set a lower “normal” limit since • In moderate airway obstruction, expiratory
both values are directly affected by both the age airflow is decreased. When air is trapped in the
and the height of the person [24]. The FEV1/FVC lungs, the FVC will have a higher value than
ratio is generally above 80%, and values below predicted. The FVC normally declines with
this may well be indicative of obstruction. In age, so that elderly persons without airway
severe airway obstruction, many airways will obstruction will have a ratio below 70% to
close prematurely and FVC will be reduced. 80%. FVC is indicative of both lung and chest
While the FEV1/FVC is reliable, even here expansion with maximal inhalation and rapid
caution is needed. The FEV1 and the FVC are maximal exhalation. It is a good indicator of
inversely related to age and height. If a fixed individual effort.
value is used, older individuals are more likely to • Children may have ratios greater than 90%
be considered abnormal [24]. [23].
Most modern spirometers measure additional
volumes during the forced expiratory maneuver. 3.3.1.1 Forced Expiratory Flow
In asthma, both the residual volume (RV) and the Maximum (FEFmax)
functional residual capacity (FRC) tend to be This measurement is often represented as the
higher than normal predicted values [26]. See peak expiratory flow (PEF) which is the highest
Table 3.2. instantaneous flow achieved during the FVC
Some general points are worth mentioning. maneuver.
3.3.1.2 Forced Expiratory Flow25-75 individuals a visual depiction of their reading. It

(FEF25-75) does not give a numerical value.
This is a subset of FEFmax. FEV25-75 is the aver- The characteristic shape of this curve, with
age flow rate over the middle 50% of the FVC. It obstruction in mainly medium-sized airways as
is usually calculated electronically by excluding in asthma, is shown in Fig. 3.5. Some abnormali-
the first and last 25% of the FVC (hence the ties have a characteristic pattern, and the flow-
“25-75”). volume loop may also provide clues to the
At the start of a forced exhalation, air is presence of other diseases such as vocal cord dis-
expelled from the lungs and trachea. At the end of ease or large airway obstruction due to tumor.
the forced exhalation, the individual attempts to A normal flow-volume loop should show the
“squeeze” all the air out of the lungs. The first expiratory flow rate as a rapid rise with a gradual
25% is an approximation of anatomical dead decline in flow back to zero. The inspiratory sec-
space, and the value of the last 25% from the tion of the loop is shown in the negative area of
smaller airways becomes difficult to interpret in the flow axis as a deep U-shaped curve. In airway
moderate to severe airway disease because of the obstruction both the inspiratory and the expira-
asymmetric closure of the smallest airways. It tory section of the flow-volume loop changes.
has been suggested that this particular measure- See Fig. 3.5. There is a rapid peak expiratory
ment provides some idea of small airway func- flow (PEF), but the gradual decline is replaced by
tion, but this is a questionable assumption, and it a curve with a concave shape indicative of a
probably adds little in the way of useful informa- marked decrease in FEF25-75. The inspiratory
tion [29]. The FEV25-75 is most useful in research flow, shown below the x-axis, is shallower, indic-
and in cases where there are equivocal values in ative of a reduction in inspiratory volume. In
the FVC. The FVC is always effort-dependent. more severe cases of asthma, the peak becomes
FEV1, FVC, and their ratio remain the primary sharper, and the expiratory flow line drops pre-
guide to disease severity. It is recommended that cipitously. The concavity of the downward slope
FEV25-75 “should not be used to diagnose small is an indication of the severity of obstruction.
airway disease in individual patients” [8]. See Fig. 3.6.
The flow-volume loops provide information
3.3.1.3 Expiratory Flow200-1200 about the effort involved. The two figures above
(FEF200-1200) show a well-defined peak indicative of good
This is also a subset of FEFmax. The first 200 ml
exhaled during the FVC maneuver and any gas
exhaled after 1200 ml are not included in the
calculation.
This measurement is very similar to the
FEF25-75 in its intent and provides similar help in
interpreting results. It is probably not required in
most cases, but computerized spirometers
generally compute and display this and other val-
ues automatically.
3.3.2 Flow-Volume Loops
The flow-volume loop provides visual represen-

tation of flow. It can help in determining whether
a valid test has been done and additionally gives
Fig. 3.5 Flow-volume loop for person with asthma
3.3 Spirometry 67
Fig. 3.6 Spirogram showing severe obstruction Fig. 3.8 Unacceptable spirogram (example 2)
Fig. 3.7 Unacceptable spirogram (example 1)

Fig. 3.9 Unacceptable spirogram (example 3)
effort [29]. Unacceptable efforts (see Figs. 3.7, 3.3.2.1 Volume-Time Curves
3.8, and 3.9) are usually indicated by: The normal volume-time curve shows a rapid
upslope that peaks and flattens (reaches a pla-
• Lack of normal early peak, indicative of vari- teau) shortly after exhalation. Figures 3.10, 3.11,
able effort 3.12, and 3.13 depict differences between
• Sharp, abrupt downward slope in the expira- volume-time curves for normal airways and for
tory curve, indicative of premature airways that have either mild or severe obstruc-
termination tion and restrictive disease. Sample FEV1 and
• Sharp spikes in the downward portion of the FVC values have been provided without refer-
expiratory curve that indicate cough ence to age or height. In asthma, the slope is
milder or less steep, with a gradual increase to the
Spirograms are not acceptable when they have point of maximum volume.
been terminated early due to cough, or if a full Figures 3.14 and 3.15 show acceptable and
inspiration was not taken at the start of the proce- unacceptable volume-time curves. Figure 3.14
dure, resulting in inconsistent forced exhalation. depicts an acceptable effort and shows the curve
An examination of the flow-volume loop pro- both before and after bronchodilator use, with the
vides a good indication of the quality of the FEV1 marked. Figure 3.15, on the other hand,
spirogram. shows a delay in exhalation, which makes the
Fig. 3.10 Volume-time curve for person without asthma Fig. 3.13 Volume-time curve showing severe restriction
Fig. 3.14 Volume-time curve showing both pre- and

Fig. 3.11 Volume-time curve showing mild obstruction post-bronchodilator volumes
Fig. 3.12 Volume-time curve showing severe

obstruction Fig. 3.15 Unacceptable volume-time curve
3.3 Spirometry 69
result unacceptable. Figure 3.15 may indicate that Individual Factors

too much air had escaped prior to the maximal At times, individuals with asthma will be unable
effort being made. D’Angelo and others showed to meet these criteria for a number of reasons.
that in normal subjects, a 4- to 6-second delay They may:
after inhalation and prior to exhalation caused a
reduction of 4 to 5% in both FEV1 and PEF [30]. • Be physically unable to carry out the
instructions
3.3.2.2 Technical Requirements • Not understand the instructions
for Spirometry • Have poor motivation, general ill health, or
The asthma educator may or may not perform physical impairment
spirometry themselves on people with asthma. • Be at the extreme age limits (too young or too
Nonetheless, it is essential that they understand old)
the technical aspects of this particular test. As
pointed out earlier, the results obtained by spi- Differences in environment (including air pol-
rometry are only as good as the equipment, the lution), nutrition, physical activity, and socioeco-
effort of the individual, and, most importantly, the nomic factors all affect lung function [8]. So does
skill and expertise of the technologist who super- smoking, which reduces FEV1 and causes an
vises the test and coaches the person. Results are annual rate of decline greater than caused by nor-
always effort-dependent, and it is important that mal aging [32, 33]. Hence, for each test, informa-
there be a good relationship between the technol- tion on the person’s gender, age, height, weight,
ogist and the person being tested. race, and smoking status must be provided.
3.3.2.3 Criteria for Acceptability The Technologist

The American Thoracic Society (ATS) and the Spirometry is not yet at the point where the
American Association for Respiratory Care equipment operates autonomously (by itself).
(AARC) have developed specific criteria for The technologist needs skills, both interpersonal
acceptability [8] of spirometry tests: and technical, in order to obtain accurate
spirograms.
• Number of trials. A minimum of three accept- The technologist must:
able trials is required.
• Acceptability. To be considered acceptable, • Help the subject perform the test correctly.
each trial must meet all three of the following This can require interpersonal skills, patient
conditions: coaching, encouragement, and similar sup-
1. There must be no false start, hesitation, portive actions.
coughing, or early termination of exhala- • Be able to assess the individual’s effort, since
tion unless the individual can exhale no the test is effort-dependent.
further.
2. The extrapolated volume must be less than In addition, the technologist requires certain
or equal to 5% of FVC, or 150 ml, which- technical skills. These include [8] the ability to:
ever is greater.
3. A rapid rise to start time is also required, • Demonstrate the FVC maneuver to the
and the test should last at least 6 seconds individual.
and give evidence of maximum effort by • Coach the person so that the onset of the
the individual [31]. maneuver begins with an exhaled “blast.”
• Reproducibility. The two largest FVC and • Observe the person through the entire
FEV1 readings should not vary by more than maneuver.
0.2 liters. The largest values for FVC and FEV1 • Provide positive feedback to encourage the
should be selected, regardless of the test used. individual to provide a maximal effort.
• Monitor the various attempts and select the professional specifically trained in pulmonary
best of them for use. function testing. Interpretation of the results
• Calibrate and maintain the test equipment demands careful attention to the equipment used,
according to the manufacturer’s directions. the person’s performance, and the reference val-
• Ensure that all necessary health precautions ues that are chosen [28, 31–35].
are taken. Unlike measures of peak expiratory flows, spi-
rometry is a useful tool for assessing progress,
Factors Affecting Reproducibility particularly in those persons whose lung function
Consistent and reproducible results require con- is compromised, or in the elderly, or in individu-
sistent and proper technique. There will be a lack als with a chronic obstructive lung disease
of reproducibility if the individual’s efforts are (COLD) such as emphysema or chronic bronchi-
inconsistent; there is an air leak in the equipment; tis. In these cases peak flows tend to be higher
or the mouthpiece is obstructed. Reproducibility than their corresponding reduced spirometric val-
may deteriorate after repeated efforts due to ues [23].
fatigue or bronchospasm (tightening of the air-
ways). In any case, after eight attempts to per-
form a single acceptable maneuver, the test 3.3.3 Bronchodilators in Pulmonary
should be discontinued. The technologist must be Function Testing
able to judge the quality of the tests and decide
whether or not more teaching is desirable, Since asthma is characterized as having revers-
depending on the person’s condition and ible airway obstruction, use of spirometry over
tolerance. time may indicate whether or not the disease
can be reversed. It is standard practice in most
Body Position laboratories to administer a bronchodilator if
Body position affects air volumes. Readings drop the FEV1/FVC ratio or FEV1 is below a prede-
by 7 to 8% when supine and by a 1% to 2% loss termined value, perhaps 10% below predicted
when sitting as compared to standing. For obese normal. Spirometry is repeated between 5 and
individuals, standing is particularly helpful [8]. 10 minutes after the bronchodilator has been
Persons with asthma may sit or stand, but what- given, and the degree of change (in the result)
ever the choice, the same position should be used is used to determine whether or not the person
through the test. They should preferably stand is responding to the bronchodilator. However,
and begin with a deep full inhalation; then, with the exact type and degree of change that should
maximal effort, they should provide a full and be observed is a matter of some debate. This is
forceful exhalation. not surprising, as bronchodilator response
The exhalation should proceed from a normal depends not only on changes in smooth muscle
“blowing out” to a “squeezing out” for a complete but also on activity in the airway epithelium
FVC maneuver without coughs and/or extra and nerves and on mediator production and
breaths. Lack of a full inspiration, a less than blocking. Further, individual bronchodilators
maximal effort, excessive variability between may vary in their effectiveness from person to
efforts, and too short an effort are also considered person.
unacceptable. As an aside, it is worth noting that Values obtained from the post-bronchodila-
prior to 1994, the AARC considered instrumenta- tor test may be expressed as a percentage of ini-
tion to be the major source of variability; since tial spirometric values (FVC and FEV1
then, the major source of variability has been expressed as a volume), as a percentage of ini-
attributed to improper performance. tial predicted baseline, or as an absolute change.
AARC’s Clinical Practice Guidelines recom- Most often, the reading provided shows the per-
mend that spirometry be administered by trained cent change against the initial predicted base-
technologists under the direction of a healthcare line value. Here again, there is debate on how
3.4 Measures of Lung Function 71
big the change should be. Values of 8% or less 3.3.4 A

Pulmonary Function Test
are within the normal tolerances of the equip- and Its Interpretation
ment. The ATS suggests 12–15% [8] as a mean-
ingful change, while the American College of Figure 3.16 presents the results of a pulmonary
Chest Physicians has suggested 15–25% [36]. function test. These are interpreted in Fig. 3.17.
Also, the reason for the test may affect the crite-
ria: bronchodilator reversibility may be done as
a diagnostic test or, in someone with known 3.4 Measures of Lung Function
asthma, to see if a bronchodilator will improve
pulmonary function. The various measures of lung function used in
Reversibility is the hallmark of asthma. If asthma are presented below.
someone has poor lung function, specifically a
low FEV1 or FEV1/FVC, and exhibits an
improvement after bronchodilator, reversibility 3.4.1 Peak Flow Measurement
has been demonstrated. This usually confirms a
clinical diagnosis of asthma. The initial mea- FEFmax (or peak expiratory flow) is the maxi-
surement is done before bronchodilator. mum rate at which an individual can expel air
Bronchodilators may give immediate systematic from the lungs. It can be measured using either an
relief, but most laboratories wait 15 minutes electronic spirometer or a handheld peak flow
after inhalation of a bronchodilator before meter (PFM). The spirometer measures FEFmax
repeating spirometry or peak flow. Reversibility in liters per second, while the PFM measures
after inhalation is not shown when the inhaled peak expiratory flow (PEF) in liters per minute;
drug is a corticosteroid and is not seen with the therefore, conversion from FEFmax to PEF
long-acting beta-2 agonist salmeterol, although requires multiplication by 60. Given the differ-
it is seen with the long-acting beta-2 agonist ence in sophistication between the two types of
formoterol. equipment, however, and the marked differences
Reversibility should not be measured if a in technique, the translation of PEF (taken by a
bronchodilator has been taken immediately handheld PFM) to FEFmax is not advisable [23,
before the test. A number of hours must elapse 38–40]. The PFM gives values at ambient tem-
before the test can commence. AARC guidelines perature, while spirometers correct values to
suggest the following waiting times for various body temperature. In addition, reference values
drugs: would need to be correlated with the specific
brand of peak flow meter; currently, these values
• Salmeterol 12 hours are not available [17].
• Ipratropium 6 hours Where spirometry is unavailable, serial mea-
• Terbutaline 4–8 hours surement of peak flow over 1 to 2 weeks may be
• Albuterol 4–6 hours used to demonstrate variability, particularly in
• Metaproterenol 4 hours those individuals where asthma is suspected but
the spirogram was normal [17]. While changes in
Most laboratories use either albuterol or the PEF may parallel changes in FEV1, PEF is less
subject’s personal bronchodilator. While an sensitive in detecting bronchoconstriction, is
improvement in the range of 15–20% is usually more effort-dependent, and is less reproducible
accepted as satisfactory [37], it is important to [41].
look at as much information as possible. In other Being essentially mechanical devices, indi-
words, the FEV, the FEV1/FVC, and shape of the vidual PFMs lose their accuracy over time.
flow-volume curves should all be examined. FEFmax may be compared against a PFM read-
Changes in any one of these may help to identify ing to determine whether the PFM is working
those individuals with reversibility. correctly or needs replacing.
Fig. 3.16 Pulmonary function test results

Interpretation of Pulmonary Function Test Results
(Letters shown below refer to corresponding entries in the charts)
[2,3]
A sample Pulmonary Function Test (PFT) result Items marked [2] are actual pre-measures and
is shown on in Figure 3-14. The results are also given as a percentage in [3]. This
sheet is explained below. adolescent female therefore has severe
obstruction with an FEV1 of 23% of
Preliminary Information predicted before bronchodilator, FEV1/ FVC
at 50 %, and FEF25-75 at 8%. The PEF is given
A, B, C, F and G for comparison, but this should not be used
This information is used to calculate normal for general PEF values. Instead, a Peak Flow
values. meter should be used.
D Location at which the diagnosis was made [4, 5]

The post-bronchodilator measures [4] and
E The date is extremely important and often the post-bronchodilator percentage values
over-looked when scanning reports. [5] show the improvement. However, they
do not reach normal since FEV1 is still only
G This is the patient’s age. 52%, and the FEV1/FVC has only risen to
60%.
Flow Volume Curves
[6]
It is worthwhile examining the time volume Post-bronchodilator [6], impressive changes
curve and the flow volume curve. The time have occurred, but their size reflects the
volume curve shows the prolonged fact that the baseline was so low.
expiration, and the difference pre-and
post-bronchodilator. Explaining the PFT
The flow volume curve shows the characteristic Unless qualified to do so, the asthma educator
scooped shape of airflow obstruction. may not interpret the findings of the test.
However, the asthma educator should
Although there is improvement after explain the following to the patient:
administering the bronchodilator, the
forced curve covers the circle in the center • the PFT shows that the patient has asthma and
(the tidal breath), showing that some that it is currently severe persistent (FEV1 is
obstruction remains after treatment. 60%).
• the test is a ‘snapshot’. It shows how the lungs
Technologist’s comments are functioning at the time the test was
conducted.
The technologist’s comments (9, 10, and 11) are • the test is the basis for determining the
also very important. They are entered after medication that will be prescribed.
the test has been completed. • the test will be kept on file, and will be
Compared against subsequent PFTs to see how
Lung Mechanics well the prescribed medication is working, and
[1] how well the patient is responding.
These items give the reference volume in liters • if the medication is taken, then there is hope for
for someone of this weight, height, gender improvement.
and age.
Fig. 3.17 Interpretation of pulmonary function test results

Despite its limitations, the PEF may be a use- • Exhaling with maximal force
ful measurement in strictly limited circum- • Noting the pointer’s new position
stances. Nowadays spirometry can be done with a • Recording the reading (PEF)
portable electronic device such as a laptop. • Repeating the maneuver for a total of three
Results of PEF are most likely to be valid when attempts and recording each reading
the person is confident, makes a full effort, and
can be followed over time. A successful effort PEF readings can easily be manipulated in
with a PFM is one that is both effort- and vol- many ways by individuals with asthma. These
ume- dependent [42]. The individual must be include:
encouraged to take a full inspiration and to then
exhale as vigorously as possible since optimal • Spitting into the device
peak flow is achieved in about one-tenth of a sec- • Flicking the pointer quickly with a finger
ond. Hence a prolonged exhalation is not neces- • Flicking the tongue or blocking the mouth-
sary. The peak flow meter measures how fast, not piece with the tongue
how long, an individual can exhale (Fig. 3.18). • Incorrectly placing the mouthpiece in front of
PEF usage should be taught by a person who the teeth and tongue
is skilled in the procedure; in addition, the indi-
vidual’s PEF technique and readings should be They may also fail to reset the pointer before
reviewed at every visit. Single measurements taking a reading. And there exists the possibility
may miss clinically important changes in func- that the numbers recorded on the chart may be a
tion, particularly in children [43–45]. figment of the imagination. Ideally, the person
Performance of a peak flow maneuver initially using a PFM should be conscientious and
requires both an explanation and a demonstration honest.
by a trained person such as the asthma educator. Despite the known problems that can occur
The sequence of steps includes: with PEF, the test can be performed with low-
cost equipment in the office, clinic, or home, pro-
• Setting the indicator on the PFM to zero vided the potential for loss of accuracy is
• Standing up straight recognized and accepted. While tables of normal
• Taking a rapid and complete inhalation rates exist (see Figs. 3.26 and 3.27 at the end of
• Placing the PFM between the teeth, on the this chapter), they were measured for Caucasians,
tongue, with lips sealed around the and other ethnic groups will have different rates
mouthpiece [12, 46]. There can be a very wide variation from
one person to another, and each individual’s PEF
reading (PEFR) needs to be reviewed periodi-
cally to determine his or her best reading.
When individuals with asthma are followed
over time and know their best PEFR, such factors
diminish in importance. Consider, for instance,
the case of a 16-year-old male student, 5 feet 10
inches (180 cm) in height, with a predicted peak
flow of 475±75 l/m. This young man went to a
clinic complaining of shortness of breath and
chest tightness. When tested, he blew 480 l/m on
his peak flow meter, which was higher than the
predicted 475±75 l/m. However, further ques-
tioning revealed that his normal PEFR was 650
Fig. 3.18 (from left to right) Pediatric, youth, and adult l/m and that he played soccer, ice hockey, and a
peak flow meters
(musical) wind instrument. Thus this student was this twice-daily testing is done over a period of
at 74% of his personal best and experiencing time, those with asthma will show an exaggerated
symptoms, and this was indicative of loss of con- morning to evening variation and other variabili-
trol of asthma. Hence the need to obtain some ties in PEF throughout the day and from one day
personal background information and to deter- and another. See Fig. 3.19.
mine the individual’s personal best reading, Ambulatory monitoring through peak flows is
before making a judgment. a useful diagnostic tool, with PEF recorded in a
The educator must seek immediate medical diary preferably for 2 weeks. When there is a
help for any adult whose PEFR is less than 180 variability of >13% in children and >10% in
l/m and must ensure that the individual under- adults, requirements for physiologic reversibility
stands the severity of the situation with such a have been met. These changes are in keeping
low PEFR. with asthma. Peak flow readings will often show
a distinct and helpful pattern. Those with poorly
3.4.1.1 Calculating Reversibility controlled asthma will show at least 20% vari-
The degree of reversibility may be calculated ability between morning and afternoon readings
using readings obtained through a peak flow (with “afternoon” defined as being between noon
meter. A PEFR should be taken, following and 2 p.m.) [17].
which a short-acting bronchodilator should be
administered. After a 15-minute wait (which is 3.4.1.3 Calculating Diurnal Variability
sufficient time for it to work and achieve maxi- Diurnal variability is calculated using a formula
mum effectiveness), a second reading should recommended by the NAEPP [6]. It is expressed
be taken. The degree of reversibility is then as the daily amplitude percent mean. That is,
calculated by dividing the second PEFR by the
first PEFR. The answer should be greater than
max daily PEF min daily PEF 100
1 and in the form “1.xx”. The number in front Mean PEF

of the decimal point should be ignored. The
two digits after the decimal point give the per- The educator can easily perform this calcula-
centage of reversibility. For instance, a person tion. For example, a person reports a morning
who blows 320 l/min before and 360 l/min PEF of 370 and evening PEF of 330. Using the
after the bronchodilator would have a degree of formula above, the diurnal variability is calcu-
reversibility of: lated as
360/320 = 1.125, that is, 12.5%.
If the “after” PEF is 380, then the degree of

reversibility would be 380/320, which is 1.1875,
or 18.75%.
3.4.1.2 Diurnal Variation

Pulmonary function varies throughout the day,
whether or not there is lung disease, being lowest
overnight and highest between noon and 4 p.m.
[40]. This daily variation is exaggerated in
asthma.
The diurnal variation can be shown when indi-
viduals with asthma use PFM at home, measure
PEF in the morning, record results in a diary, and
repeat the measurement in the evening. When Fig. 3.19 Peak flowchart showing daily variation
370 330 100 4000 used to indicate when to seek medical help and
11.43% when to intensify treatment [43, 48]. Wide diur-

370 330 2 350 nal variability and significant bronchodilator
A variability of 12% or less in daily readings reversibility can be used in the estimation of
is acceptable. However, if the lower reading is asthma control.
320, then the diurnal variability changes: Many individuals, however, will see the mea-
surement exercise as a chore or nuisance and will
370 320 100 5000 not be enthusiastic about doing it regularly or fre-
14.49%

370 320 2 345 quently [49]. PEF use should hence be encour-
aged when there is a specific reason, so that they
This is close to 15%, which is indicative of are more likely to cooperate.
asthma that is not in control. If the lower reading Figures 3.20, 3.21, and 3.22 illustrate typical
were 300, then the formula would give a diurnal real-life scenarios that the educator will encoun-
variability of 20.9%, which indicates uncon-
trolled asthma.
3.4.1.4 Consistency in Obtaining PEF

Readings
PEF tends to peak in the middle of the waking
day. As mentioned earlier, it is important for indi-
viduals with asthma to take two or three PEF
readings each time and to record the best, but it is
equally important not to exceed three, since mul-
tiple attempts at PEF may induce reactivity and
lead to a sharp fall in PEF readings.
PEF readings should also be taken at the same
times each day. For most individuals, this means
a morning measurement, prior to any medication
being taken, followed by an evening measure- Fig. 3.20 Peak flowchart for person under good control,
ment, after a reliever medication has been taken who gets a cold and develops symptoms after some days.
[17]. Evening readings tend to be more conve- There is a slow response after treatment is doubled
nient for most people. However, since the highest
PFR occurs between noon and 2 p.m., an evening
reading will tend to underestimate the diurnal
variation.
3.4.1.5 PEF and Adherence

While PEF readings are not as reliable as FEV1
[47], they can be very useful since they provide
measurements over a period of time (days to
weeks) of the person’s airway lability (openness
and degree of obstruction) while in their natural
setting. The readings can demonstrate the effects
of allergens or viral infections and show the
improvement in asthma with drugs such as
Fig. 3.21 Peak flowchart for a person with some degree
inhaled steroids or oral corticosteroids. They can of control who is exposed to a trigger, catches a cold,
also be used in action plans to guide the takes prednisone (an oral steroid), and then shows some
individual’s response to deterioration, by being improvement
3.4.2 O
ther Measures of Lung
Function
3.4.2.1 Fraction of Exhaled Nitric Oxide

(FeNO)
Nitric oxide is a biologic mediator produced by
the lung. It plays a role in the pathophysiology of
asthma and is present in exhaled breath.
Measurement of nitric oxide, expressed as frac-
tion of exhaled nitric oxide (FeNO), can be help-
ful in determining the degree of inflammation
within the lungs. The FeNO test is noninvasive,
simple, safe, and easily repeatable in individuals
Fig. 3.22 Peak flowchart of a person with poorly con-
trolled asthma who responds to inhaled corticosteroids
with severe airflow limitation. It can also be used
over several days in children.
Normal FeNO levels are dependent on race,
age, height, and sex, being higher in males [52–
ter. Persons with asthma should be taught to rec- 54]. Levels of FeNO are lower in children, but
ognize these situations, so that they can self-assess increase as they age. Levels are also affected by
their health and the effectiveness (or otherwise) atopy, disease severity, current therapy, smoking
of their medication regime. Each diagram shows status, measurement technique, obesity, and other
a distinctive pattern that starts with a decline in diseases. Higher levels are found in atopic indi-
PEF values over a period of a few days. viduals and lower levels in tobacco smokers [55].
Intervention then occurs, after which an increase FeNO correlates significantly with peripheral
in consecutive PEF readings is observed. This is blood eosinophil counts in people with asthma; it
typical for an exacerbation due to an allergen can hence be used to distinguish between asthma
exposure or viral infection. and COPD [56].
For many individuals, the PFM is a valuable FeNO is measured in parts per billion (ppb)
and useful tool. For others, it is yet another irri- using chemiluminescence analysis of exhaled
tating reminder of asthma and an additional bur- breath. It is helpful in caring for individuals with
den on their lives. Hence, the educator should asthma in that it can:
discuss PFM use with each person, rather than
recommend it to everyone. It is worth remember- • Aid in the diagnosis of asthma especially in
ing that people may be compliant in their use of those >5 years who are unable to perform
the PFM in the short term, but not for prolonged spirometry
periods of time [35]. In cases of mild to moderate • Detect eosinophilic airway inflammation
asthma, the PFM does not provide helpful infor- –– therefore, a step in identifying the
mation when the person is well. When the person phenotype
is ill, equally useful information may be gained • Predict and monitor response to therapy
by counting the number of extra doses of rescue • Evaluate a current exacerbation
medication used as by doing a PEF. Nevertheless • Predict a future exacerbation
PEF may be helpful for a limited time in some • Evaluate adherence to medication regimen
individuals [38, 50, 51]. The NAEPP Guidelines • Monitor response to anti-inflammatory
[13] strongly encourage the use of peak flow therapy
meters in individuals with moderate to severe • Aid in titrating type and dose of medication to
asthma. improve asthma control
FeNO can also be used to screen people sus- • The specificity and sensitivity of the FeNO
pected of having asthma or individuals with non- testing process depend on the clinical situa-
specific symptoms. It can also be a guide to tion. However, in corticosteroid-naïve indi-
further testing since those with asthma have viduals with asthma, FeNO measurement is
increased exhaled NO levels compared to those most accurate for ruling out the diagnosis of
without asthma [57, 58]. However, FeNO levels asthma when the result is less than 20 ppb. In
can be difficult to interpret, because they will this situation, the test has a sensitivity of 0.79,
depend on the individual’s age and weight, level a specificity of 0.77, and a diagnostic odds
of atopy, use of ICS or oral steroids, and asthma ratio (OR) of 12.25.
phenotype [59]. • Inhaled corticosteroid treatment should not be
FeNO levels can also be used to determine the withheld solely based on low FeNO levels.
degree of sensitization of persons prone to occu-
pational asthma. A prospective study by Wild and 3.4.2.2 Dilution Techniques: Helium
colleagues [60] of apprentices in 2-year programs and Nitrogen
for baking, pastry-making, and hair dressing As noted, there is always some air remaining in
found that in comparison with non-sensitized the lung, no matter how forcible or prolonged the
individuals, FeNO levels were expiration. This is residual volume (RV). RV is
increased in poorly controlled asthma and creates
• 83% higher in highly sensitized individuals mechanical disadvantages in respiration and
• 30% higher in mildly sensitized subjects hence an increase in the work of breathing. It can-
not be measured by spirometers that give infor-
They concluded that the levels of sensitization mation about tidal volume, inspired and expired
were “early markers of airway inflammation.” volume, vital capacity, and inspired capacity.
The most recent recommendations [61] make Residual volume measurements require the
it clear that FeNO has “a supportive role when use of either dilution techniques using helium
the diagnosis of asthma is uncertain.” FeNO (He) or nitrogen (N) or a plethysmograph.
results should never be used on their own to diag- Dilution techniques using He or N work well if
nose asthma, but is a relevant adjunct test. The the gas in the lung communicates with major air-
update comments on specific levels of FeNO: ways and hence with the gas in the mouth. They
permit functional residual capacity measurement;
• FeNO levels of < 25 ppb (or < 20 ppb in chil- when combined with inspiratory capacity from
dren ages 5–12 years) are inconsistent with T2 the spirometer, they also allow total lung capacity
inflammation and suggest a diagnosis other to be measured. If parts of the lung are blocked,
than asthma (or that the individual has asthma such as by a mucus plug, and there is gas behind
but their T2 inflammation has been managed the mucus plug, then the dilution techniques will
with corticosteroids or they have non-T2 not give accurate values.
inflammation or non-eosinophilic asthma). Helium is an insoluble gas. It is not absorbed
• FeNO levels > 50 ppb (or > 35 ppb in children by the body and is not present in the lungs in life.
ages 5–12 years) are consistent with elevated For the dilution test, the individual breathes
T2 inflammation and support a diagnosis of through the spirometer in a closed circuit. Then a
asthma. Individuals who have T2 inflamma- known amount of He is inhaled, and then breath-
tion are more likely to respond to corticoste- ing continues until equilibrium is reached. During
roid treatment. the process of reaching equilibrium, the volume of
• FeNO levels of 25 ppb to 50 ppb (or 20–35 gas in the system remains constant as oxygen is
ppb in children ages 5–12 years) provide little abstracted in the alveoli. Oxygen is added to the
information on the diagnosis of asthma and mixture being breathed to replenish the amounts
should be interpreted with caution and atten- being removed by the alveoli, and carbon dioxide
tion to the clinical context. (CO2) is removed from the exhaled gas as it
appears. At the start, the volume and the concen- V1 is the FRC and is the unknown that is to be
tration (percentage) of He in the spirometer are measured.
known, and therefore the amount of He can be cal- P2 is the final pressure at the mouth and is equiva-
culated. At the end of the test, the percentage of He lent to alveolar pressure.
is measured, and this will be lower than the start- V2 is FRC plus the change in lung volume (V).
ing percentage because of dilution by FRC. FRC
is then calculated using a simple formula. The plethysmograph can also be used to
In the nitrogen washout test, the basic assump- measure resistance. In any tube, including the
tion at the start of the test is that air in the lung airways, the driving pressure is related to the
has the normal concentration of 21% oxygen (O2) difference in pressures between one end of the
and 79% nitrogen (N). The test commences with tube and the other. This driving pressure over-
the individual breathing 100% O2 until the nitro- comes resistance, which in the case of a gas
gen in the lung is washed out, a process that usu- that is made up of the viscosity of the gas and
ally takes between 6 and 8 minutes. The the tube size. Resistance is calculated as the
percentage of N is measured continuously in pressure difference (between the inlet and out-
exhaled air, and therefore the amount of N in let) divided by the flow rate. It is measured in
FRC is known. Since this is 80% of total FRC, centimeter H2O/L/sec. In normal adults at
FRC can be readily calculated. FRC, this varies between 0.5 and 1.5. Lung
volume affects airway resistance, and airway
3.4.2.3 Plethysmography resistance (RAW) is measured at FRC
The plethysmograph, or body box, gives very (Fig. 3.23).
accurate information, not only on volumes and Conductance is the reciprocal measure of
capacity but also on airway resistance. Its main RAW and is also related to lung volume.
component is the body box, which is a sealed, Conductance is highest at high lung volume, is
airtight chamber. The individual sits inside the usually measured at known lung volumes, and is
body box wearing a noseclip and breathing then called the specific conductance.
through a tube passing out of the box. A known Plethysmography is not required for routine
volume of gas is injected into the box at the start diagnosis or assessment of individuals with
of the test, and the resultant pressure change is asthma but can give useful information in special
noted. At the end of exhalation, the breathing situations. It should be requested in those with
tube is shut by a valve. At this point the pressure airflow limitation and air trapping to check FRC
at the person’s mouth is atmospheric and there- and thoracic gas volume (TGV) or for a diagnosis
fore known. The respiratory muscles try to work, of restrictive lung disease [8].
but the closed shutter means that air cannot be
breathed in and therefore the thorax enlarges.
This simultaneously lowers the pressure inside
the thorax and increases the pressure in the box
around the person (because the individual’s body
volume increases).
To obtain its results, the plethysmograph relies
on Boyle’s Law, which relates pressure to vol-
ume. The equation for Boyle’s Law is:
P1V1 = P2 V2
where
P1 is the pressure in the mouth, is atmospheric

pressure, and is known. Fig. 3.23 Plethysmograph, with child
3.5 Bronchial Challenge Testing 3.5.1 Methacholine and Histamine

Challenge
Challenge testing, also known as bronchial prov-
ocation [62], is used in diagnosis and research. It Methacholine and histamine are the substances
is essentially the opposite (or reverse) of the test most often used in challenge tests. While
for reversibility after the use of a bronchodilator. responses are similar [69, 70], methacholine is
In challenge testing of individuals with normal or preferred as it has fewer side effects [8, 70, 71].
near-normal spirometric values, an inhaled sub- These tests are reliable and produce a fall in air-
stance (generally, methacholine) or a respiratory flow in many with normal baseline spirometry,
maneuver is used with the intention of causing but should be done in an approved pulmonary
some deterioration. For deterioration to be function laboratory with approved reagents [72,
observable, a baseline reading or assessment 73]. While the procedure for methacholine is
must be present. Hence, it is important that any described here, the procedure for histamine is
challenge test be done after an adequate clinical similar.
and spirometric assessment. Baseline FEV1 and/or PEF are performed
Challenge tests are not only not needed in before a very dilute solution of methacholine is
those with clear abnormalities on spirometry; given. After an appropriate delay, FEV1 and/or
they may be dangerous in this situation. While PEF is repeated. If there is a fall of 20%, the test
the procedure is safe in those with normal or is terminated and considered positive. The fall of
near-normal pulmonary function, facilities 20% is referred to as the “PC 20,” and it involves
should be available for treatment should there be comparing the highest FEV1 pre-test with the
unexpected severe deterioration [63]. Individuals highest FEV1 post-test [74]. PC20 refers to the
should not be left alone during the test and a concentration of methacholine or histamine, and
healthcare provider, skilled and able to treat PD20 refers to the cumulative dose of histamine
bronchospasm, should be close at hand. or methacholine used. For practical clinical pur-
Therapist safety is also a concern, and care is poses, these measurements are interchangeable
necessary to prevent staff exposure to the metha- [75], but in research studies, there may be subtle
choline. Absolute contraindications to methacho- but important differences between PD20 and
line challenge include severe airway obstruction, PC20 [63]. See Fig. 3.24.
such as FEV1< 50% predicted (although the If there is no significant change in the mea-
challenge will give no useful information if FEV1 surements after the first inhalation, doubling
is <85% predicted), heart attack or stroke in the dilutions of the methacholine are given until
last month, uncontrolled hypertension, and aortic there is a fall in FEV1 of at least 20%. Once PC
aneurysm [64]. 20 has been achieved, a bronchodilator is given
Challenge tests using methacholine and hista- and FEV1 and/or PEF remeasured. Full recovery
mine, both in extensive clinical use, are direct. may take more than 60 minutes [76], and the
Tests such as exercise, adenosine 5'-monophos- individual should stay at the test facility until
phate (AMP), and non-isotonic aerosols are indi- recovery is assured. If the fall has not been
rect [64, 65]. achieved by the time a dose of 16 mg/ml of
Allergen-based challenges can be done, but methacholine has been given, the test is consid-
these are usually reserved for research studies or ered negative. By omitting some of the dilutions
unusual clinical situations including suspected of the methacholine, the test can safely be per-
occupational exposure [66]. At one time, a posi- formed in a much shorter time [77, 78].
tive challenge test was thought to be specific for Challenges have been performed on young chil-
asthma, but positive tests are seen in other lung dren in university laboratories using auscultation
diseases such as COPD [67] and cystic fibrosis [79], the interrupter [80], and computerized anal-
[68]. ysis of lung sounds [81].
3.5 Bronchial Challenge Testing 81
[82]. Hence challenge testing may be used to rule

out or confirm a diagnosis of asthma that is sug-
gested by the individual’s history. It may also be
used to determine the risk of developing asthma
or to evaluate the severity of asthma [65, 72].
3.5.2 Exercise Testing
Exercise testing is an indirect test of bronchial

hyperresponsiveness, but of immediate direct rel-
evance to individuals. It may be more specific
than methacholine or histamine challenge and
Fig. 3.24 A time-FEV1 graph showing the initial drop in
FEV1 on exposure to histamine and the return to normal
can be used to help establish a diagnosis of
after inhalation of albuterol asthma. It can be useful when alternative diagno-
ses such as vocal cord dysfunction (Chap. 4) are
a possibility. Sequential exercise challenges in
The diagnostic use of challenge testing is gen- the laboratory, at intervals of weeks or months,
erally reserved for puzzling situations—for can be used to help assess the effectiveness of
example, when symptoms are atypical but asthma treatment.
is a possibility. While the diagnosis of asthma is Exercise Challenge Tests, as used in the
made by history, some with normal standard spi- assessment of asthma, should not be confused
rometry may be reluctant to accept the diagnosis with progressive exercise testing. This latter is
without a confirmatory laboratory test. Challenge used to assess degree of fitness and to help distin-
testing can be useful in this situation. guish between cardiac and lung disease. In a pro-
An example of the use of research based on gressive exercise test, there is a very gradual
challenge testing is a follow-up study of preterm increase in workload at 2-minute intervals, and a
infants, some of whom had evidence of intrauter- large number of measurements are taken includ-
ine growth retardation. Bronchial responsiveness ing inspired and expired oxygen and carbon diox-
to methacholine was correlated with a number of ide, tidal volume, respiratory rate, minute
clinical features, and it was shown that intrauter- volume, and oxygen saturation. There are many
ine growth retardation had not led to the develop- different variations, but the important features of
ment of bronchial hyperresponsiveness [82]. the Exercise Challenge Test are [71]:
A correlation exists between bronchial hyper-
responsiveness (BHR) and disease severity for • No warm-up
persons with asthma. For these, an increase in • Rapid achievement of maximum work
BHR is indicated by an increase in symptoms, • Duration of at least 5–6 minutes at maximum
lower peak flows, increased diurnal variation, exertion
and a more intense response to stimuli [82]. • Careful observation of the test subject (as a
However, many may have BHR but not have safety measure)
asthma, or may have BHR for transitory periods • Bronchodilator available for emergency use
due to a respiratory infection. BHR is associated • Use of bronchodilator at end
not only with asthma but with a number of other
diseases such as COPD, cystic fibrosis, conges- The clinical features of exercise-induced
tive heart failure, bronchitis, and allergic asthma (EIA) are described in detail in Chapter 4.
rhinitis. Knowledge of how to induce EIA may give some
Allergic sensitization and eosinophilic inflam- clues on how to prevent it. Exercise causes bron-
mation are known to increase BHR in children chodilation first. Bronchoconstriction then occurs
after about 6 minutes of continuous exercise at Table 3.3 Variations in heart rates
80% of aerobic metabolism. This stabilizes or Age Normal heart rate
“plateaus” for about 2 minutes. If exercise con- < 6 months 80–160
tinues, the bronchoconstriction will increase. 6 months–1 year 80–130
1–5 years 75–120
Approximately 15 minutes after the start of exer-
5–14 years 70–110
cising, assuming the exercise has stopped, mod- Over 14 years 70–110
erate bronchoconstriction will resolve Description Heart rate
spontaneously. There is then a refractory period Level of fitness Decreases with high level of fitness
that may last for minutes or hours [67, 83, 84]. Sleep state Decreases while asleep
Temperature, humidity, allergen exposure, pol- Medication Increases when beta-2 agonists taken
lutants, exercise workload, duration of exercise, Exercise Increases with (during) exercise
Illness and fever Increases
and degree of airway hyperreactivity all affect the
severity and duration of the bronchoconstriction.
Test conditions should be controlled in a labo-
ratory. Baseline FEV1 and PEF are obtained and
oxygen saturation (SPO2) is measured through-
out the test. Many laboratories also measure air-
way resistance by plethysmography at the start
and end of the test. While contraindications are
similar to those for methacholine challenge,
unstable cardiac ischemia and severe dysrhyth-
mias may also occur. Individuals with other dis-
eases such as orthopedic conditions may not be
able to exercise under test conditions.
After the baseline measurement, the individ-
ual runs on a treadmill whose speed and slope are
increased rapidly. Throughout the exercise, heart Fig. 3.25 Peak flow readings taken over time as a patient
exercises, showing the initial increase in peak flow fol-
rate and respiration are measured continuously. lowed by a sharp drop. Albuterol inhalation causes the
The person should not exceed the maximum rec- peak flows to return to normal
ommended heart rate for age (see Table 3.3), and
PEF should be monitored throughout the test.
After 6 minutes of exercise, the treadmill is to relieve symptoms. However, a negative exer-
slowed down quickly, and the individual repeats cise test does not exclude asthma—it does not
both FEV1 and PEF. Tests are repeated over the mean that the person does not have asthma.
next 10 minutes as the phenomenon could be bet- Exercise challenge testing can be performed
ter described as post-exercise bronchoconstric- in other venues including an office or clinical set-
tion rather than exercise-induced asthma. Once ting. In such situations PEF might be the only
the challenge test has been shown to be positive, measurement, and monitoring is done by obser-
or whenever the person is distressed, a broncho- vation. If free running is used, the individual
dilator must be given and observed until recov- should run on a level area, and not up and down
ery. See Fig. 3.25. stairs. There are differences between running
If 6 minutes of exercise cannot be tolerated, indoors and outdoors in terms of exposure to irri-
the test should be terminated earlier. The typical tants and allergens. Free running, if used, should
reduction seen in FEV1 and PEF occurs just after continue for 6 minutes, with PEF measured every
the end of exercise. During exercise there may be minute for the next 4 to 5 minutes. PEF will usu-
a paradoxical increase in FEV1 and PEF. If the ally fall in this time period, and a bronchodilator
measurement falls by 20% after exercise, the test will then be needed for symptomatic relief [72].
is positive, and the bronchodilator must be given See Table 3.3.
3.6 Other Testing Methods 83
Special care must be taken when interpreting 3.5.4 Ultrasonic Distilled Water
the results of an exercise challenge for an athlete.
Exercise-induced asthma is extremely common This has also been used to determine whether or
in athletes, particularly in swimmers or where not bronchial reactivity is present. In one study
cold air is present [85–90]. If beta-2 agonists are [63], individuals had both a methacholine chal-
to be used in competitive venues, then the benefit lenge and an ultrasonically nebulized distilled
may need to be established by formal testing. water (UNDW) challenge and then completed a
Given the complexity of international Olympic questionnaire. The UNDW challenge was carried
regulations, and the importance for athletes to out by inhaling increasing volumes of distilled
obey precisely all rules about medication use, the water. Those persons with asthma showed a posi-
educator should seek advice from someone expe- tive response to UNDW, whereas the normal sub-
rienced with the health condition of the athletes jects did not. There was a good correlation
before ordering or carrying out testing and before between UNDW and methacholine [94].
making specific recommendations. The educator
should also seek help from a medical advisor
familiar with Olympic regulations. 3.5.5 Adenosine 5’-Monophosphate
(AMP)
3.5.3 Inspired Cold Air AMP induces bronchoconstriction, which is

thought to be due to histamine release from mast
This is another indirect measure of airway hyper- cells [95], and has been shown to be a suitable
responsiveness that may be relevant to those ath- clinical test. It has been suggested that it is a
letes who have asthma symptoms in cold air. In rapid test for population screening [96], but other
general use, the results obtained by using cold air investigators have felt that it is not sensitive
to demonstrate airway hyperresponsiveness are enough for population studies and that methacho-
broadly similar to those obtained from the use of line challenge should be used [97].
methacholine [91].
The test procedure using cold air is almost
identical to that described for exercise. FEV1/ 3.6 Other Testing Methods
PEF is measured, and then cold air (at 20° C or
68° F) is inhaled for 2 to 3 minutes. Then FEV1/ 3.6.1 Bronchoalveolar Lavage (BAL)
PEF is repeated, and the test is considered posi-
tive if a reduction of 20% from the baseline is Bronchoalveolar lavage (BAL) is a way of
observed. obtaining information about the cellular content
In one specific protocol employed with chil- of the lower airways and alveoli in both health
dren, air at 15°C was used over 4 minutes. CO2 and disease. It came into clinical use with the
levels were kept constant. FEV1 was measured at development of the fiber-optic bronchoscope in
4, 6, and 8 minutes postchallenge, but in fact, the 1970s. The bronchoscope is inserted into the
changes had occurred by 4 minutes, which would airway under general anesthesia or with seda-
seem to be a suitable time to terminate the test tion and local anesthesia. The airway, starting at
[92]. the vocal cords, is first inspected. The broncho-
A more complicated multiple-step cold air scope is advanced and “wedged” in a lobar
challenge has also been used, with a series of bronchus or segmental bronchus depending on
3-minute cold air steps, with the degree of the age and size of the patient and the skill of
ventilation being increased at each step. A sim- the operator. An aliquot of normal saline is then
pler single-step approach, using one period of 4 inserted, and then the washings, “lavage fluid”,
minutes only, was shown to give comparable aspirated into a specimen jar. The specimen is
results to a more complicated step technique [93]. analyzed for cell count, type of cells, and a vari-
ety of inflammatory mediators; the same proce- BAL is indicated in clinical practice in those
dure is usually repeated in another lobar with respiratory symptoms and where a sus-
bronchus or segmental bronchus and the other pected diagnosis is not clear. Examples might be
lung. Typically the specimen will also be sent tracheomalacia in children and tumors in adults.
for microbiological analysis, to ensure there is BAL has a role in those with persistent asthma
no viral, bacterial or fungal explanation for the symptoms and abnormal pulmonary function.
respiratory symptoms. The results can be used Before BAL is scheduled, it should be estab-
to guide treatment and to help in phenotypic lished that the person with asthma is adherent to
description. an appropriate level of inhaled corticosteroid and
One early study reported that cells and pro- that diagnoses other than asthma have been
teins obtained by BAL were comparable to excluded. Here BAL will guide the use of more
results regarding inflammatory issues using open advanced therapies.
lung biopsies [98]. This particular study focused Currently, BAL is also a valuable research tool
on patients with inflammatory and immune pro- in assessing new compounds that may be valu-
cesses and a variety of disorders, including infec- able in specific asthma phenotypes.
tious malignant and interstitial disease. The same
authors predicted that BAL “will yield major
insights into the pathogenesis, staging, and ther- 3.6.2 Induced Sputum
apy decisions.” This prediction has proven true in
the case of asthma, and BAL is now a very impor- Induced sputum is obtained by asking the person
tant procedure to be carried out in those patients with asthma to inhale hypertonic saline (3–5 %)
who are characterized as having “difficult to con- and then cough up the sputum produced into a
trol asthma.” A more recent study was carried out cup. The same analyses as in BAL are carried out
in healthy volunteers and patients with mild, on the sputum, and acceptable results can be
moderate, and severe asthma [99]. In all of those obtained [101]. While the analysis of induced
with asthma, whatever the severity, there was sputum might give less detailed information from
eosinophilic inflammation and also shedding of different areas of the lung than the same analysis
the epithelium. Inflammation associated by carried out after BAL, it is a test that can be
neutrophils was seen only in those with severe administered in an office setting [102]. At this
asthma. stage in the evaluation of asthma, induced spu-
The use of BAL is becoming increasingly tum should be considered in the early assessment
important. As pointed out in Chapter 1, the cur- of those with “difficult to control asthma,” with
rent approaches to therapy are based on estimates BAL reserved when the traditional results cannot
of severity in which the lowest dose that gives be obtained by any other method.
control is prescribed. The current approach is
simplistic requiring the right choice of ICS and
providing it at the right dose. As previously 3.6.3 E
xhaled Breath Condensate
noted, asthma has several phenotypes and more (EBC)
than one type of pathology, although clinical fea-
tures may be very similar. The use of phenotypes EBC is another noninvasive way of finding out
and endotypes defined by clinical features and what is happening inside the lung. It is clearly
response to therapy is in the process of being much more convenient than either induced spu-
replaced by classifications in which asthma is tum or BAL. In essence, the breath is collected
subdivided into subtypes defined by biomarkers. into a sterile container with preservative and
Particularly in those with asthma that is difficult then sent for analysis. The analysis should look
to control, the results from BAL in health and for the same inflammatory markers sought for
classification can indicate a more personalized by other methods. However this technique is
disorder and therefore a personalized approach to bedeviled by the drawback that we do not
treatment [100]. exactly know the exact location, in the airways,
3.8 Pulmonary Function Testing in Infants and Preschool Children 85
from which the droplets of fluid come. Hence, on infants and preschool children should be
it is nearly impossible to do a quantitative anal- designed specifically for that age group. Obvious
ysis as there will be wide range in the volume issues such as dead space and resistance to air-
of the droplets, all from a variety of sources. flow are really important in ensuring the test can
This method may become useful, given its be done properly and interpretable values
great convenience, but more research is obtained. Any equipment developed for this age
required before an asthma educator should group should allow longitudinal assessments to
consider its use [103]. be made.
It is important at any age, particularly for the
preschool child, to monitor disease progression
3.7 Oxygen Saturation and to ensure that long-term treatment fulfills its
aim of giving adequate control of disease. Any
This test differs from most of the tests mentioned technologist involved in testing infants and young
so far. It gives unique information of physiologi- children should be specially trained in testing this
cal value at one moment in time, oxygen satura- age group and as an obvious prerequisite must be
tion (SpO2) that varies from moment to moment. comfortable when dealing with children. The
It refers to the amount of oxygen carried in hemo- technologist should also have the skills to put the
globin and is related to the partial pressure of O2 child and the accompanying parent at ease.
in the blood (PaO2). Values of SpO2 are in the It is possible to carry out spirometry at the
range 95–100% at sea level and are slightly lower upper level of this age group, perhaps children
(around 92%) at higher altitudes. Saturation is age 4 or 5. Testing such children requires great
measured noninvasively and easily by placing a patience and frequently is unsuccessful, even
probe on the skin that uses light to determine the with the best technologist and using appropriate
oxygen saturation of hemoglobin [104]. The equipment in terms of dead space and low resis-
device identifies the pulse and then the saturation tance to airflow. While it might be worthwhile
(pulse oximetry SPO2) and is widely used in EDs making an attempt at spirometry in some chil-
and in laboratories (during, e.g., exercise testing). dren, persistence when the child is having prob-
Educators will not use it routinely, but when a lems performing the maneuver may make it
person has been to an ED and reports that the “sat nearly impossible to engage the child for the test
was 80%,” it is an indication that the attack was described in the next sections that can readily be
severe. SpO2 is routinely measured in exercise done in preschool children.
and challenge tests.
3.8.1 Pulmonary Function Testing

3.8 Pulmonary Function Testing in Infants
in Infants and Preschool
Children Tests are available for this age group, and they
have been validated. Normal values are also
This is an important topic. Lung disease may known. The major drawback is that the testing
have its earliest manifestations in the first few equipment available is cumbersome, is time-
months of life, and the various lung diseases may consuming to use, and requires sedation. Such
well show significant progression before the tests are usually performed by specially trained
child is old enough to perform standard technologists, and typically a physician is present
spirometry. throughout the testing. Given the complexity
Testing of preschool children of any age is involved, it is not unreasonable for formal written
usually carried out in specialized facilities, consent to be obtained from the parents for the
although some techniques such as the interrupter procedure [105].
and the forced oscillation techniques may be suit- Initially sedation is used, most often chloral
able for more general use. Any equipment used hydrate, and then the infant is fitted with an inflat-
able vest around the thoracic cage. An airtight cies of oscillation (4–32 Hz). Provided some
mask is then placed over the infant’s nose and agreement can be reached between the flows on
mouth and connected to computerized equipment the various frequencies to be used, this test is
to measure airflow and pressure. Functional very promising and gives the possibility of doing
residual capacity (FRC) is measured after tho- longitudinal measurements and also immediately
racic compression (“squeeze”). repeating an individual test after bronchodilator
Additional techniques sometimes used include to see whether there is any specific change (i.e.,
plethysmography. In principle, the system is sim- fall) in resistance [106].
ilar to that used with children and adults, but of
course scaled down. The child will be asleep (in 3.8.2.2 Interrupter
other words relaxed) and will be placed supine in This is a technique that enables calculation of the
the plethysmograph with a facemask sealed interrupter resistance (Rint), and while it is rela-
around the mouth and nose. This technique can tively easy to perform, there is not full agreement
also be used to measure FRC, and in this situation between laboratories on the necessary standard-
the respiratory circuit is closed and inspiration ization. The fundamental assumption is straight-
occurs, perhaps two or three times. The pressure forward, if airflow is abruptly interrupted at the
inside the box is plotted against the pressure at mouth, there will be rapid equilibration of alveo-
the mouth, and the slopes of the various efforts lar pressure. The commercially available equip-
are used to calculate the FRC. A visual impres- ment consists of a flowmeter, a device to measure
sion can also be made available of a partial flow- pressure, and a valve to interrupt the flow. The
volume loop. As in spirometry, concavity in this child will be seated and, as in another test, will
loop would suggest there is some limitation to bear a noseclip and will breathe quietly through
flow in the small airways. the mouthpiece. The mouthpiece will be between
the teeth. This test usually requires two operators.
One will support the child’s cheeks, and the other
3.8.2 Pulmonary Function Testing will ensure the mouthpiece is in position and that
in Preschool Children the lips are sealed around it. The child then
breathes quietly, and the valve automatically
Two tests are described, the forced oscillation closes in response to a preset trigger flow. It will
technique and the interrupter, as it is feasible to remain closed for a brief period, usually around
perform both tests in a normal pulmonary func- 100 milliseconds. After the airway is occluded,
tion laboratory that is set up to test children. the change in airway pressure represents the drop
in resistance across the respiratory system. There
3.8.2.1 Forced Oscillation Technique are a number of different ways of calculating this
(FOT) value [20].
This test can be done on most preschool children,
and while it obviously cannot be done if the child
opposes testing, it does not require complete 3.9 Pulmonary Function Testing
cooperation. The child has a mouthpiece and a of Adults Unable to Do
noseclip, and the technologist holds the child’s Standard Spirometry
cheeks firmly. The child breathes normally, and a
noise signal is generated and superimposed on Adults may be unable to do spirometry for a wide
spontaneous breaths. Pneumotachographs and variety of reasons including degree of illness,
differential pressure transducers are used. The energy level, and cognitive level. Some combina-
signals are fed to a microcomputer, and using a tion of the tests described above may be used,
fast Fourier transform algorithm, spectral analy- such as the interrupter or oscillometry. These
sis performed. This allows a measure of measurements can be supplemented by measur-
resistance, usually expressed at various frequen- ing, for example, oxygen saturation and by sim-
3.10 Quality Control 87
ple measurement of respiratory rate before and ensuring, at the same time, that they are not stig-
after administration of the bronchodilator. matized in any way. Precautions should also be
taken when individuals have open sores on the
oral mucosa. Infection is more likely to be trans-
3.10 Quality Control mitted by indirect contact—usually aerosol drop-
lets will contaminate the mouthpiece and some of
Quality control deals with all aspects of testing, the valves and tubing of the spirometer.
from the reliability of the equipment to the tech- Technologists should carefully wash their
nical and human qualities of the technologist. hands before and after each contact and should
While variability in any laboratory tests is inevi- wear appropriate gloves. Where possible, dis-
table the aim of a good quality control program is posable single-use equipment should be used,
to minimize the variability. This requires careful especially for items such as mouthpieces which
attention and maintenance of the equipment, to come in direct contact with the mucosal surface.
keep it working to the manufacturer’s specifica- If not disposable, such items must be sterilized
tions. Specific standards, recommended by the after each use. Tubes, valves, and manifolds
American Thoracic Society (ATS), exist for the also require frequent disinfecting. If there is any
equipment and these must be met or exceeded concern, the manufacturers of the equipment
[8]. When purchasing equipment, the detailed should be consulted for advice on optimal ster-
specifications, independently verified, need to be ilization. Tubing should be flushed several times
available. Equipment should also be certified and after use by every person with asthma to ensure
approved for use on humans. that droplet nuclei are cleared. These precau-
Given that many of the tests are effort depen- tions are emphasized by the National Committee
dent, the skill and personality of the technologist for Clinical Laboratory Standards (NCCLS)
supervising the test also become extremely [108] recommendations for quality care and by
important for success. the Centers for Disease Control’s (CDC) proce-
The technologist should have background dures for the prevention of exposure to infection
training in spirometry and pulmonary function [109]. All respiratory diagnostic procedures
testing generally together with additional, spe- should follow these recommendations and
cific training in the equipment that they will be procedures.
operating [72]. The technologist should be famil- Spirometers must be calibrated daily, and the
iar with ATS standards of accuracy [8]. They temperature, humidity, barometric pressure and
should have adequate social skills and be com- altitude must also be entered. Spirometers must
fortable dealing with people, as a maximal effort meet or exceed ATS requirements. Technologists
will not be obtained if the technologist cannot who perform spirometry must ensure that proper
encourage individuals to achieve their best. procedures are followed for the care, cleaning,
The laboratory should be clean and should be and calibration of the spirometer and that the
well laid out to allow ease of access to the equip- same technique is used consistently. At regular
ment. In addition to the spirometer, there should intervals, equipment must be disassembled to
be access to oxygen and to bronchodilators. If the allow full cleaning to be carried out. It is impor-
laboratory offers challenge testing, facilities for tant to recalibrate the equipment each time it is
resuscitation should be available. disassembled and reassembled [110].
Infection control procedures are part of good Thus, to summarize: for any lung function test
laboratory practice [107]. The same equipment to be successful, three essential components need
will be used by many different individuals, and to work together harmoniously: the equipment,
infection may be transmitted to them or to staff the technologist, and the individual with asthma.
by either direct or indirect contact. In terms of Only then can the best possible level of informa-
direct contact, particular care needs to be taken tion become available, either for confirmation of
when testing persons with hepatitis or HIV while diagnosis or for monitoring purposes.
3.11 Application own peak flow readings, both morning and

evening. Calculate diurnal variability.
1. Obtain and review the pulmonary function
3. With the cooperation of a few individuals with
tests for ten individuals with asthma. In the asthma, note their peak flow readings both
first table below, record the gender, age, race, before and about 15 minutes after they have
weight, and height and smoking status of each taken a bronchodilator. Using the chart below,
individual, followed by their FEV1, FVC, calculate the degree of reversibility (Tables
FEV1/FVC, and PEF. 3.4 and 3.5, Figs. 3.26 and 3.27).
2. Obtain a peak flow meter and a peak flow-
chart. Over a period of 2 weeks, note your
Table 3.4 for use with Application question 1

No. Age Gender Height Weight Smoking Race FEV1 FVC FEV1/FVC PEF
1
2
3
4
5
6
7
8
9
10
Table 3.5 for use with Application question 3

Peak expiratory flow readings (PEFR)
No. Age Gender Predicted Pre-bronchodilator Post-bronchodilator Degree of reversibility
1
2
3
4
5
6
7
8
9
10
3.11 Application 89
Fig. 3.26 Normal peak

expiratory flow values in
adults. (Recreated from
Gregg I, Nunn SJ. Brit
Med J. 1973; 3:282)
Fig. 3.27 Normal peak

expiratory flow values
for children aged 5
through 18. (Recreated
from Gregg I, Nunn
SJ. Brit Med J. 1973;
3:282)
5. Pattishall EN, Helms RW, Strape GL.

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Clinical Presentation of Asthma
4
Contents
4.1 Introduction 96
4.1.1 Symptoms: Overview 97
4.1.2 Detailed History 97
4.1.3 Physical Examination 99
4.1.3.1 Palpation 101
4.1.3.2 Percussion 101
4.1.3.3 Auscultation 102
4.1.3.4 Other Components of Examination 102
4.2 Investigations: Spirometry 103
4.2.1 Other Investigations 103
4.2.2 Trial of Therapy 104
4.3 Asthma Severity 104
4.3.1 Classification of Severity Before Treatment 107
4.3.2 Risk Domain 108
4.4 Patterns of Asthma 109
4.4.1 Important Factors Contributing to Severity 112
4.4.1.1 Phenotypes of Asthma 112
4.4.1.2 Exercise-Induced Asthma 113
4.4.1.3 Nocturnal Asthma 114
4.4.1.4 Allergies, Asthma, and Seasonal Changes 115
4.4.2 Occupational Asthma 115
4.5 Life-Threatening Asthma 116
4.5.1 Severe Acute Asthma (Status Asthmaticus) 116
4.5.2 Brittle Asthma, Catastrophic Asthma 117
4.6 Differential Diagnoses 117
4.6.1 Wheeze and Lung Disease 117
4.6.2 COPD and Asthma 118
4.6.3 Hyperventilation 118
4.6.4 Vocal Cord Dysfunction (VCD) 119
4.6.5 Bronchial Obstruction 119
4.7 Time Course of Events in Asthma 120
4.7.1 Response to Exercise 120
4.7.2 Response to Allergens 120
4.7.3 Response to Viral Infection 120

96 4 Clinical Presentation of Asthma
4.8 Diagnostic Problems in Asthma 121

4.8.1 Age-Related Asthma 121
4.8.1.1 Less Than One Year of Age 121
4.8.1.2 One to Five Years 123
4.8.1.3 Five to Twelve Years 123
4.8.1.4 Twelve to Twenty-Five Years 123
4.8.1.5 Twenty-Five to Thirty-Five Years 123
4.8.1.6 Thirty-Five to Sixty Years 123
4.8.1.7 Sixty Years and Above 123
4.9 Sex and Gender Differences in Asthma 124
4.10 Avoiding Delays in Diagnosis 125
4.11 Monitoring Asthma 126
4.11.1 Fraction of Exhaled Nitric Oxide (FeNO) 127
4.12 Referral to a Specialist 127
4.13 Application 128
References 128
Key Points Chapter Objectives
• Presentation of asthma After reading this chapter, you should be

–– Symptoms, past and family history, able to:
physical examination and
investigations 1. Discuss and differentiate between the
• Assessing severity of asthma and its different patterns of asthma.
classification before treatment 2. List those diseases that may be confused
• Patterns of asthma with asthma.
• Important factors contributing to 3. List the problems in diagnosing asthma
severity at different age levels.
–– Genotype and phenotype 4. Explain how to monitor asthma and

–– Sex and gender differences assess for severity.
• Review of time course of events in 5. Identify those individuals who should
asthma with response to exercise, aller- be referred to a specialist.
gens, viral infections
–– Nocturnal asthma and seasonal
changes
–– Occupational asthma 4.1 Introduction
• Life-threatening asthma including severe,
acute, brittle, and catastrophic forms Asthma may present to the healthcare profes-
• Diagnostic problems in asthma by age sional as:
and selected conditions
• Differential diagnoses • Recurrent cough, especially cough that dis-
–– Including COPD, hyperventilation, turbs sleep
vocal cord dysfunction, and bron- • Wheeze
chial obstruction • Dyspnea on exertion, whether during daily
• Avoiding delays in diagnosis activities or formal exercise
• Monitoring asthma • Acute severe asthma in the emergency
• When an educator may need to refer to a department
specialist
4.1 Introduction 97
Other presentations may be less obvious: after exercise or allergen exposure, but this is
only one of several distinct patterns.
• Recurrent colds or colds that never seem to go People with asthma cannot all be classified
away neatly into any one particular pattern of asthma,
• Prolonged cough following a cold and patterns will change in an individual from
• Recurrent pneumonia one time to another. Some patterns are more
• Recurrent bronchitis common at one particular life stage than another.
• Chest pain The collection and review of information
• Fatigue about the individual with symptoms is a prerequi-
• Lack of fitness site for diagnosis and assessment. The most use-
ful piece of information is the history.
History will include information on the
4.1.1 Symptoms: Overview response to treatment in the past. A review of hos-
pital, physician, or healthcare provider reports is
It is important to start with symptoms, since also useful and will help the healthcare provider
these, after all, are what are felt and lead to ask- to know more about the person with asthma. After
ing a healthcare practitioner for help. When deal- a history has been obtained, a physical examina-
ing with anyone with asthma, it is essential to tion and spirometry can be performed; then, other
constantly return to the symptoms and to ensure investigations may be ordered depending on the
that effective mechanisms are available to help initial findings. Physical examination will provide
the individual deal with symptoms and, better extremely useful additional information, but the
still, help in symptom prevention. history remains the most important single item in
Cardinal symptoms have been described ear- diagnosis and assessment.
lier, in Chap. 1. Of all the symptoms, cough, This is being written in the midst of the
wheeze, and dyspnea are the most important and COVID-19 pandemic, and the pre-eminence of
generally the most distressing. The features of history has been reinforced. Many consultations
asthma are heterogeneous, as is its presentation. can be completed safely, effectively, and satisfac-
A person may present with asthma at any time torily by phone. The additional use of a video
between infancy to old age, with enormous varia- source, such as Zoom, FaceTime, or Skype,
tions in severity. ensures that almost all essential information can
Asthma behaves in many different ways, yet be obtained remotely.
individuals, including healthcare professionals,
may have a stereotypical view of this condition.
The most common stereotype is often of an indi- 4.1.2 Detailed History
vidual who becomes wheezy after exercise or
after allergen exposure and who then must go to As noted, history is essential for the correct diag-
an emergency department for treatment. This is nosis of asthma, and it should be obtained for
only one stereotype, and it is usually based on patients of any age, whether or not they are capa-
limited exposure to just a few people with asthma. ble of providing measurements of FEV1 or PEF
Those with asthma may also have stereotypi- (forced expiratory volume in 1 s or peak expira-
cal views and will often say “But I cannot have tory flow in liters/min) [1].
asthma – I only cough at night!” or “I do not have The history may reveal that when symptoms
asthma – I never wheeze – I am never in the of asthma (cough, wheeze, breathlessness, or
Emergency Department.” A condition as com- chest tightness, either singly or in combination)
mon as asthma (affecting between 10% and 15% were observed, a bronchodilator aerosol medica-
of the population) must and will vary widely in tion was given and there was rapid resolution of
all of its manifestations, and it is this wide varia- the symptoms. If the symptoms improve within a
tion in behavior and in severity that is the cause few minutes or so, this history can be considered
of the confusion. One stereotype is that of wheeze diagnostic of asthma.
When obtaining the history, questioning has to Other factors must also be considered: Is there
be gentle but very specific. The time course of exposure to known environmental allergens such as
response to a bronchodilator is very important. For animal dander, pollens, molds, and other items? Is
example, when patients describe improvement there exposure to occupational chemicals or aller-
with a bronchodilator, it is important to question gens? Has any variation in symptoms been observed
further, to determine just when this improvement as a result of a change, such as a vacation or a move
occurred. When patients state clearly that dramatic into a new home? What is the reaction, if any, after
improvement occurred following use of a bron- exposure to irritants such as tobacco smoke? To
chodilator, then this is strongly suggestive of a emotion, such as crying or laughing hard? To medi-
direct effect. When the bronchodilator is said to cations (e.g., aspirin, beta-blockers)? To consump-
produce improvements over a few hours or a few tion/ingestion of food? To food additives and/or
days, it is probably better to assume that this has preservatives? If female, to menses and pregnancy?
resulted more from the natural course of the illness
than from the effectiveness of the bronchodilator. (c) Duration of the symptoms
In acute severe asthma, however, the effectiveness
of bronchodilators may be reduced until sometime How long have there been symptoms sugges-
after systemic corticosteroids are taken. tive of asthma? Note that such symptoms may
There is a general problem both in gathering often pre-date the diagnosis of asthma. Often,
evidence about asthma and knowing when treat- there are symptoms (e.g., in infancy) which are
ment for asthma has made a difference. The rea- given a variety of labels of uncertain definition
son for the confusion is the natural variability of such as “bronchitis” or “pneumonia” or “reactive
the condition and the fact that improvements will airway disease (RAD).”
often happen with time and general care, but In an adult, it is important to ask specific ques-
without specific treatment. In other words, the tions to determine if there was onset in infancy or
major challenge is to decide whether improve- early childhood, although the adult may not be
ment has occurred because of the treatment … or able to provide an answer.
despite the treatment.
Answers to the following questions should (d) Variation of the symptoms from morning to
form part of the history. night
(a) Specific symptoms It is essential to find out specifically if there

are symptoms during the night, as often these
Is there cough, wheezing, shortness of breath, will not be mentioned without direct questions.
chest tightness, or sputum production? How Are symptoms present during the night? Are they
many of these symptoms occur? How often do different from daytime symptoms?
they occur? Do one or more of them occur at the
same time (i.e., together)? Are there other condi- (e) Response to previous treatment
tions associated with asthma which may cause
symptoms such as nasal problems (rhinitis, sinus- What treatment and medication have been
itis, polyps) or eczema? given in the past? Which of these was helpful,
and in what way did it help? Did any of the treat-
(b) Factors which bring on or worsen the
ments cause other problems?
symptoms
(f) Variation of symptoms by season
This is important, and specific mention should
be made of the response to viral respiratory infec- Is there a time of year when symptoms are
tions. Most people have colds every year. How worse? Is there a time of year when the person is
did this person respond to the last cold they had? symptom-free?
4.1 Introduction 99
(g) Last exacerbation (j) Asthma knowledge
Individuals with asthma tend to refer to an It is useful to know the level of knowledge
exacerbation as an “attack.” They should be each individual has about their own health, what
asked to describe their most recent exacerbation they know about asthma, and about its causes.
in detail. What symptoms preceded the exacerba-
tion? Were there any problems (emotional, physi- (k) Finances
cal, personal) that may have precipitated the
exacerbation? What did the exacerbation itself It is important to understand whether asthma
consist of (or feel like)? What symptoms accom- is causing financial problems.
panied the exacerbation itself? How did the exac-
erbation end? (l) Family history
(h) Environment It is necessary that a history of asthma and

other atopic disorders in the immediate family
Educators should also ask for a detailed and close relatives be taken. A general medical
description of the home, work environment, history needs to be done for coexisting diseases.
and any recent job changes. In addition, answers
should be obtained about pets and renovations.
Specifically, are there pets or smokers in the 4.1.3 Physical Examination
house, or in any homes visited recently? Has
any renovation or redecorating (including A visual examination should begin from the
painting, wallpaper, and so on) been done moment the educator meets the person with
recently? asthma. Immediate important observations
include how quickly or slowly the person walks,
(i) Impact of having asthma whether there is any abnormality of gait (suggest-
ing neurological illness), and whether or not
Some time should be spent in dealing with the there is any obvious breathlessness. The respira-
individual’s feelings about asthma and its impact tory rate should be counted surreptitiously at
on them. This information can be obtained some convenient time during the interaction—
through a number of indirect questions: knowledge that their breath rate is being esti-
mated will likely lead to an increase in the rate
• How many times has the person visited the and depth of breathing. The presence of a cough,
emergency department? whether dry, hacking and irritating, or loose and
• Have there been any life-threatening productive, will be easily heard. If the lips are
exacerbations? blue, indicating central cyanosis, urgent action
• Have many school or work days been must be taken as this is a serious condition.
missed? Then the pulse should be measured and the
• Is the individual able to take part in physical fingers inspected at the same time. The presence
activities, such as sports or physical education or absence of finger clubbing needs to be estab-
classes for children, and activities of daily liv- lished. Finger clubbing is a swelling of the end of
ing for adults? each digit and loss of the normal angle at the base
• Do they wake up at night? of the nail. See Figs. 4.1 and 4.2.
• Are medications such as oral corticosteroids Finger clubbing is not a feature of asthma. A
being taken? person with asthma who has clubbing should be
investigated for one of a number of serious lung
It may be further helpful to discuss how all diseases such as lung cancer, lung abscess, and
these factors affect the family. cystic fibrosis. In the days before cardiac surgery
Inspection of the ear with an otoscope is

important, particularly in children. Chronic ear
problems in children may cause problems in
overall management and may need to be assessed.
Inspection of the nose may show a small
crease on the bridge of the nose. This is often
seen in adults who have had chronic nasal prob-
lems in childhood and who have rubbed their
nose frequently. This crease results from the con-
stant pushing up of the tip of the nose by the
hand, and this action is called the “allergic
Fig. 4.1 Finger clubbing, front view. (© The Asthma salute.” There may be dark shadows under the
Education Clinic Ltd) eyes (known as “allergic shiners”), again in asso-
ciation with rhinitis and sinus problems related to
allergy. The nasal bridge should be inspected, to
determine whether or not it is straight. Deviation
of the bridge is not a feature of asthma, but if
there is deviation, there may be nasal obstruction
that may worsen symptoms.
Then the individual should be asked to sniff
with both nostrils, then each one in turn with the
educator using a finger to close off the other nos-
tril. The nose can be inspected with an otoscope
for evidence of obstruction, for possible secre-
tions that may be clear or purulent, and for
Fig. 4.2 Finger clubbing, side view. (© The Asthma
inflamed, red or boggy allergic mucosa.
Education Clinic Ltd) Occasionally polyps or foreign bodies will be
seen in the nose.
Next, the educator should gently tap over the
was possible, finger clubbing was seen com- site of the nasal sinus to check for any tenderness.
monly in children with cyanotic congenital heart The mandible can then be inspected to see
disease. Finger clubbing is also seen in some whether there is micrognathia (abnormal small-
liver and bowel diseases. Familial finger clubbing ness of the jaw), as this may cause its own respi-
is uncommon but not associated with any specific ratory obstruction.
diseases. When inspecting the mouth, the teeth and pal-
The order in which the formal physical exami- ate should be scrutinized; if obvious dental prob-
nation is then done will depend on the situation, lems can be identified, the educator should
the age and sex of the individual, and the gender recommend that the individual visit a dentist. In
of the educator. children, adenoids may be seen in the posterior
Approaching the individual more closely, the pharyngeal wall.
educator should check for mouth odor that may Then the neck should be gently palpated for
be a clue to dental problems, sinus infection or lymph nodes and also to determine if the thyroid
pneumonia, or some other issue. An assessment is enlarged. The trachea should be palpated to see
of the person’s voice is also important, both for if it is midline.
hoarseness (suggestive of laryngeal problems) Inspection of the chest should be done next.
and for difficulty in articulating more than two or This requires adequate attention to privacy and
three words, suggestive of respiratory appropriate draping, but also sufficient exposure
impairment. to allow the chest to be carefully inspected.
4.1 Introduction 101
There should be some estimate as to whether abnormal appearance of the chest is due to
or not the person is obese. Chest wall deformities chronic trapping of air, leading to hyperinflation.
are difficult to identify in obese individuals.
The shape and obvious deformities of the 4.1.3.1 Palpation
chest should be noted. The most common defor- Palpation (using the hands to feel for abnormali-
mities are asymmetry, either of the front or the ties in the chest) is an important part of the exam-
back. At the back, this is usually associated with ination. Both hands should be placed on the
scoliosis or kyphoscoliosis. Pectus carinatum posterior part of the chest, with the thumbs joined
(pigeon chest), pectus excavatum (an indentation in the midline. The person’s breathing, both in
in the trachea), and Harrison’s sulcus (indenta- and out, should be gently felt. This will convey
tion on the ribs corresponding to where the dia- the depth of respiration and its symmetry. Then,
phragm is inserted) may be seen. See Fig. 4.3. the neck should be palpated to see if there are any
Harrison’s sulcus is a feature of long-standing swollen lymph nodes in it. These are not a feature
lung disease in childhood. Retractions around the of asthma but may indicate other diseases. In
area of the trachea, or in the neck, immediately severe acute asthma, there may occasionally be
below the breastbone, or in the intercostal spaces air leak from the lungs into the pleural or medias-
need to be identified. In infants the sternum itself tinal spaces. If into the pleural space, the air may
may be indented. The configuration of the chest track under the skin and cause crepitus (a crack-
should be noted. Children with chronic untreated ling sensation under the fingers when air tracks
asthma will have a barrel-shaped chest—that is, into the neck under the skin) to be felt in the neck.
an increase in the anteroposterior diameter. The Palpation should be continued to the front of
the chest. The trachea should be felt to ensure
that it is midline. The hand should then be placed
over the site of the cardiac apex to ensure it is in
a normal position. The apex may be displaced if
there is asymmetrical lung disease or if the heart
is enlarged. Finally, the hands should be placed
over the lower part of the sternum. If there is
severe chronic lung disease with right ventricular
hypertrophy, a distinct heave may be felt.
4.1.3.2 Percussion
Percussion involves tapping the surface of the
chest with fingers to evaluate the size, consis-
tency, and absence or presence of fluids inside the
chest. In health, lungs sound hollow because they
are filled with air. Hence, percussion elicits noise
varying from dull (solid-sounding) to resonant
(hollow-sounding) depending on how much air is
in a particular area of the lung, whether there is
fluid in the pleural space, or whether there is an
area in the lung without air, as in pneumonia.
Percussion is particularly difficult to interpret, for
example, in obese persons since there is a thick
layer between the examiner and the internal
organ.
Fig. 4.3 Chest wall deformity. (© The Asthma Education To conduct percussion, the middle finger of
Clinic Ltd) one hand is pressed against and laid parallel to
the ribs, while the middle finger of the other hand vesicular breath sounds, rather low pitch in
is used to make a short, quick light tap. If there is quality, with a longer and louder inspiratory
no lung tissue, as in a frank pneumothorax, the phase and a shorter expiratory phase. When lis-
noise will be obviously hyperresonant; if the lung tening to normal breath sounds, about one-third
is hyper-expanded, it may be hyperresonant of the respiratory cycle is composed of inspira-
although not quite so obviously. If the lung is col- tory sounds and the remaining two-thirds, expi-
lapsed, there may be areas of dullness. Finer ratory sounds.
degrees of hyperresonance and dullness are best Bronchial breath sounds indicate an abnor-
learned by experience, although the high-pitched mality in the lungs. These sounds are normally
sound of a pneumothorax is characteristic. There detected over the trachea, but when heard in
is marked dullness over solid tissue such as the peripheral parts of the chest are suggestive of
liver, and the same note can be heard over parts of pneumonia or obstruction. Additional sounds are
the lung when there is, for instance, a pleural wheezes and crackles.
effusion or pneumonia. When tapping to percuss Wheezes are high-pitched whistling sounds
the chest, a comparison of one side with the other with a musical quality that are produced by nar-
side should be done sequentially, noting asym- rowed airways and heard mainly in expiration.
metries. In people with asthma, asymmetries will Wheezes may be produced by a forced expira-
be the most important feature. Other findings on tion. Wheeze is generally not heard in individuals
percussion may indicate diagnoses other than with asthma who are not in an exacerbation. It
asthma. may be produced (and detected) by having the
individual run for a short time and then listening
4.1.3.3 Auscultation to the chest or by forced prolonged expiration
Detailed auscultation is essential in the physical during auscultation, forcing some small airways
examination and so the next part requires the use to close. Wheeze, whether at rest or induced,
of the stethoscope. Again this must be done with does not necessarily indicate asthma. Wheeze in
due attention to the individual’s need for privacy. asthma that is produced only on exercise or by
Auscultation is the method of listening to the prolonged expiration is indicative that it is milder.
sounds of the body through a stethoscope. It In an asthma exacerbation, wheeze can be loud
involves listening to the frequency, intensity, enough to be heard by the unaided ear.
duration, number, and quality of sounds. When Crackles resemble the sound created by rub-
listening to the lungs, the intention is to listen for bing a length of hair between the fingers while
normal breath sounds, decreased or absent breath holding it close to the ear. It can be a clicking,
sounds, and abnormal breath sounds. The inten- bubbling, or rattling sound in a portion of the
sity of the sounds depends on many factors lung. It is thought to occur when air opens closed
including the location of the stethoscope, the alveoli. Crackles may be heard in both inspira-
willingness of the individual to take deep breaths, tion and expiration.
and other factors such as obesity.
In health, breath sounds are louder in chil- 4.1.3.4 Other Components
dren than in adults. The educator should prac- of Examination
tice and develop experience with a stethoscope. These will depend on each individual and situa-
The stethoscope itself should be of good quality, tion. A detailed examination of the cardiovascu-
not too long (30–40 cm), with a diaphragm for lar system may be needed. Blood pressure should
high-pitched sounds and a bell for lower pitches. always be checked. There is generally a differ-
Sounds heard are generally described in terms ence of about 10 mm Hg in blood pressure
of their loudness or volume (amplitude), their between inspiration and expiration, although this
timing (inspiratory, expiratory, or both), pitch can be difficult to detect. In severe acute asthma,
(high, medium, or low), and character (fine, there will be pulsus paradoxus, a fall of more
medium, or coarse). Healthy individuals have than 10 mm Hg in inspiratory blood pressure.
4.2 Investigations: Spirometry 103
It is important to ask about skin disease and • Fully evaluate the asthma
inspect any lesions to further determine if there is • Exclude other disorders
active eczema. In older children, adolescents, and
adults, eczema is particularly visible in the flex- These may include:
ures in the elbow and behind the knee. Even
when healed the skin appears to be thickened (a • A complete blood count.
condition known as lichenification) and often • Chest X-ray. This is done to rule out other
there is dryness. causes of airway obstruction, but it is impor-
tant not to be misled by an X-ray. While it is
also important to order an X-ray when needed,
4.2 Investigations: Spirometry X-rays ordered when not medically indicated
may give misleading information. In asthma,
Physical examination frequently is normal in the chest X-ray will be normal or show minor
individuals with asthma, and no physical prob- changes of inflammation or overinflation.
lems are detected. Given this fact and the recog- • The changes seen with mucus plugs (atelecta-
nition that auscultation does not help in assessing sis) may be confused with the shadows seen
obstruction of airflow [2], spirometry is essential. with pneumonia. Such abnormalities may be
This must always include FEV1, FVC, and a minimal and/or patchy or may involve whole
FEV1/FVC ratio. The flow volume curve has a lobes. The middle lobe has a slit-like opening
characteristic shape in the presence of obstruc- that is readily plugged with mucus and is
tion, and it may also disclose upper airway disor- therefore the most likely lobe to have atelecta-
ders that mimic asthma. The test should be sis due to mucus plugging. Some children
repeated after a dose of a bronchodilator. In the with middle lobe syndrome will turn out to
future FEV6 may be used in assessing pulmonary have asthma.
function instead of the FEV1/FVC ratio, as FVC • Abnormalities relating to heart disease or of
does not need to be measured [3]. the ribs or spine may be seen on the chest
When the diagnosis is particularly difficult or X-ray.
in unusual situations, additional pulmonary tests • Skin tests to common inhaled allergens
may be needed. These would include: • Total IgE is commonly raised in allergic
individuals
• PEF measurement at home every morning and • IgE to specific allergens will give similar
evening for 2 weeks, followed by a review. information to skin tests
When asthma is present, a characteristic • Electrocardiograph (EKG), if there is suspi-
morning-to-evening variation may be cion of heart disease.
observed.
• A bronchial provocation test with exercise. As Other tests, ordered much less often, would
described earlier, this can be done in the office include:
with peak flow, or in a pulmonary function
laboratory on a treadmill. • Sinus X-rays.
• Bronchial provocation test with methacholine • Evaluation of esophageal pH for gastroesoph-
or histamine. ageal reflux.
• Specific tests for immunological deficiency
diseases (if there are unusual features
4.2.1 Other Investigations present).
• Staining of sputum or nasal secretions for
Investigations other than spirometry should be eosinophils, which if the eosinophils are seen,
done where appropriate, to: would be strongly suggestive of asthma.
Eosinophils are a marker of inflammation. and made it clear that a new understanding is
However, this test is not often done. needed of what asthma itself really is. This need
• Bronchoalveolar lavage (BAL) which is an for a new realignment of ideas is summarized in
invasive test and not done by an educator. In a landmark report “After asthma: redefining air-
those with asthma that is difficult to control, ways diseases” [4]. The report points out that,
supplementary information by BAL (on, e.g., even though a number of new treatments are now
cells in the airway) may guide choice of available, a replication of these therapies has
therapy. been far from optimal. It specifically calls atten-
tion to a “continued reliance on outdated and
unhelpful disease labels, treatment and process
4.2.2 Trial of Therapy frameworks, and monitoring strategies, which
have reached the stage of a challenged veneration
It is not unusual to make a trial of treatment to see and has subsequently stifled new thinking.” This
whether some objective measure improves. These report is likely to become ever more influential in
measures would include either peak flow or pul- the course of the next few years. In this book the
monary function and the individual’s ability to descriptions of asthma, asthma severity, asthma
respond to exercise or improvement in symp- phenotypes, and asthma management will follow
toms. Before a trial of therapy is started, the per- current conventions, but always in the back-
son with asthma and healthcare provider should ground should lie the reality that many of those
agree very clearly: conventions are likely to change.
It is vitally important to distinguish between
• That this is a trial, over a set period of time. asthma that is truly severe and asthma that is
• On what the outcome should be in terms of merely poorly controlled. Severe asthma might
symptom improvement. be the appropriate description for someone whose
previous moderate symptoms have been ignored
It is quite appropriate to conduct a trial of or inadequately treated, who is exposed to more
treatment over a short time period with a bron- than one trigger simultaneously, and requires
chodilator, over a period of 2–4 weeks with treatment in an intensive care unit. It is more than
inhaled steroids, and over a period of 1 week with likely that this person will be given an explana-
oral or systemic steroids. tion and education on the topic of asthma and
will be prescribed appropriate prophylactic ther-
apy. If there is good adherence to the therapy,
4.3 Asthma Severity then the asthma will become controlled over the
long term.
As indicated in Chap. 1, it is neither easy nor Having said that, it should be noted that some
straightforward to define severe asthma. Even if people with asthma never achieve control despite
an easy-to-use definition did exist, the reality is excellent diagnostic and therapeutic interven-
that the severity of asthma varies enormously. tions. Thus one reason for poor control of asthma
This variation in severity is between one individ- is lack of recognition that the disorder exists.
ual and another and, even in one individual over Another reason for “poor control” is that the per-
time, can be as short as 24 h and as long as a son does not truly have asthma, but some other
lifetime. This section will deal in more detail lung conditions, or does have asthma with other
with the components of the definitions of asthma major comorbidities. In both of these cases, the
severity. action is clear; if asthma is not the underlying
Severity has become ever more important diagnosis, then a more complete diagnostic pro-
today. The complexity of asthma itself is being cess is required that will point to appropriate
recognized at the same time as new treatments therapy. If comorbidities are present, they should
have both raised the hopes of people with asthma always be identified, and if therapies are avail-
able, such therapy should be used. Other reasons At present, therefore, “severe asthma” is a retro-
that are dealt with throughout this book are spective label. It is sometimes called “severe
refractory asthma” since it is defined by being
• Inadequate doses of medication for the fre- relatively refractory to high-dose inhaled therapy.
quency of symptoms. With the advent of biologic therapies, however,
• Continued exposure to triggers such as severe the word “refractory” is no longer appropriate.
allergy to animals. Asthma is not classified as severe if it mark-
• Financial barriers to obtaining either health- edly improves when contributory factors such as
care or appropriate prescriptions. inhaler technique and adherence are addressed or
corrected.
An overarching reason, and the justification The starting point for the asthma educator in
for this book, is inadequate education. Those any discussion will be the perception of symp-
people with asthma who receive help from the toms by the person with asthma. For example,
readers of this book will themselves have a sound people who are on high-dose corticosteroids and
understanding of the condition and the various who have no symptoms may describe themselves
ways of managing asthma. as having a mild condition. On the other hand,
These introductory considerations will allow a some individuals may avoid any preventive treat-
deeper understanding of the definitions in use at ment and have daily symptoms. Those latter indi-
present. viduals may have their condition assessed as
The following is taken from the GINA pocket severe, but an asthma educator may realize that
guide [5]: the symptoms will disappear with low-dose pre-
Uncontrolled asthma includes one or both of ventative therapy and some environmental
the following: changes.
The asthma educator should decide on the
• Poor symptom control (frequent symptoms or severity of asthma at the end of the assessment
reliever use, activity limited by asthma, night and then use the information gathered overall to
waking due to asthma). make some preliminary assessment about the
• Frequent exacerbations (≥ 2/year) requiring long-term, or underlying, severity of asthma in
oral corticosteroids (OCS), or serious exacer- that person.
bations (≥ 1/year) requiring hospitalization. Thus a number of factors need to be consid-
ered when assessing severity:
Difficult-to-treat asthma is asthma that is
uncontrolled despite GINA Step 4 or 5 treatment 1. Frequency of symptoms
(e.g., medium- or high-dose inhaled corticoste- Do mild cough and wheeze occur twice a
roids (ICS) with a second controller; mainte- week or more? Do these symptoms resolve
nance OCS) or asthma that requires such spontaneously or do they require one, two, or
treatment to maintain good symptom control and more doses of bronchodilator?
reduce the risk of exacerbations. It does not mean Do symptoms occur twice a week or more;
a “difficult patient.” In many cases, asthma may and are there severe exacerbations requiring
appear to be difficult-to-treat because of modifi- treatment in the hospital several times per
able factors such as incorrect inhaler technique, year? Does daily wheezing occur, with fre-
poor adherence, smoking, or comorbidities, or quent visits to emergency departments or
because the diagnosis is incorrect. healthcare providers, or hospitalizations?
Severe asthma is a subset of difficult-to-treat 2. Symptoms and exercise
asthma. It refers to asthma that is uncontrolled How do the symptoms affect daily life? Are
despite adherence with maximal optimized ther- they able to attend school or work regularly
apy and treatment of contributory factors or that with no absences? Are absences few, or are
worsens when high-dose treatment is decreased. they frequent? Can normal or vigorous exer-
cise be performed? Can moderate—but not As mentioned earlier, their perceptions about
vigorous—exercise be tolerated? Is activity their asthma may differ from those of the health-
limited? care providers. The person with asthma will be
3. Symptoms and sleep. aware of his or her symptoms, sometimes referred
Do night-time symptoms occur less than once to disparagingly by healthcare providers as “sub-
or twice per month? Once a week? Two to jective.” The healthcare provider and educator
three times per week? Every night? will consider reported symptoms and will use the
4. Medication use information in combination with objective mea-
Asthma severity can also be determined sures of health status to determine the degree of
through the amount and type of medication severity [9].
required to control it. This is only valid if the When assessing severity, the healthcare pro-
diagnosis is correct, the healthcare provider vider should ask a number of “standard” ques-
and the person have worked out a successful tions about
treatment approach, and there is good adher-
ence to the plan. Classification after treatment • Bronchodilator use
is discussed in detail in Chap. 6. • Exercise tolerance
5. Pulmonary function • Nocturnal asthma
Spirometry results should be normal or mildly • Attendance at school or work
abnormal. A persistent abnormality of FEV1 on • Adherence to long-term control therapy.
pulmonary function would indicate that the
asthma is at the least, poorly controlled. Some The answers will help determine the action
of the considerations noted earlier will help in required and the type and dose of medication to
determining degree of control. One index of be prescribed. For example, if a beta-agonist is
severity recommended by both the American required daily on a symptomatic basis, it should
[6] and British [7] guidelines is FEV1 or PEF be assumed that the asthma is not controlled and
expressed as a percentage of the predicted value, immediate action should be taken. In terms of
with a qualifier to further delineate the asthma. exercise tolerance, they should be encouraged to
lead a full life, and strategies should be devised
• An FEV1 of less than 60% is classified as that will allow them to exercise. Note that house-
severe persistent. hold chores are a legitimate form of exercise.
• An FEV1 between 60% and 80% is classi- Questions about the effort needed to climb stairs
fied as moderate persistent. will also provide an indication of severity. Asthma
• An FEV1 of greater than 80% is classified severity has been closely connected to respiratory
as either mild persistent or mild intermit- infections, particularly if the respiratory infection
tent, depending on PEF readings. If PEF was the initial trigger of asthma. Respiratory
variability is between 20% and 30%, the infections have been correlated with air pollu-
classification is that of mild persistent. A tion, cigarette smoke, and night-time disturbance
PEF variability of <20% is classified as as triggers of asthma [10].
mild intermittent asthma. People with asthma should be able to live nor-
• Peak flow should be greater than 80% pre- mal lives. They should be able to attend school or
dicted, with occasional or no variability. work and sleep without significant night-time
More severe asthma has daily variability disturbance. When discussing night-time asthma,
greater than 30% [8]. it may be appropriate to check whether daytime
• If there is no reversibility, alternate diagno- events lead to late-onset reactions and thus night-
ses should be considered. time attacks; whether house dust mites or other
possible triggers in the home are present, espe-
Severity at that moment in time should be cially in the bedroom; etc. and to devise ways of
assessed whenever a person with asthma is seen. dealing with these events [11].
4.3.1 Classification of Severity For children aged 5 and above and for adults in
Before Treatment this intermittent category of severity, symptoms
should occur on 2 days or fewer a week and night-
The Expert Panel Report 3 from the National time awakenings twice a month at most. Short-
Asthma Education and Prevention Program acting beta-agonist usage will not be over 2 days
(NAEPP) [6] uses asthma severity as an initial a week for the relief of symptoms, and there will
guide to treatment. The complexity surrounding not be any interference in daily activities.
the concept was discussed earlier in the Lung function, added to the impairment
chapter. domain for the 5–11 age group, includes both
NAEPP’s 6-Step approach to treatment is FEV1 and the FEV1 /FVC ratio. FEV1 should be
intended, respectively, for treatment of intermit- over 80% and the ratio should be greater than
tent, mild, moderate, or severe persistent asthma 85%. In those 12 and older, the FEV1 should also
based on the two major domains of impairment be above 80%, and the FEV1 /FVC ratio should
and risk. be normal in intermittent asthma. Note that these
Impairment relates to the individual’s current lung function measurements are not particularly
health and includes: reliable in children under the age of 5 and hence
have not been included in the classification of
• Frequency of daytime symptoms severity.
• Frequency of nocturnal awakening In the risk domain, there may be one exacer-
• Frequency of use of a short-acting beta- bation per year. The Guidelines emphasize the
agonist excluding pre-treatment prior to fact that exacerbations of any severity can occur
exercise with any class of severity, hence the need for an
• Interference with normal daily activities by Asthma Action plan for every person with
the limitations imposed by the disease asthma.
Risk relates to the future occurrences of Mild Persistent Asthma

asthma. It involves minimizing the frequency of Children with asthma under the age of 5 may
exacerbations, reducing both fixed airflow limita- have daytime symptoms more than twice a week;
tion and the long-term side effects of have night-time awakenings once or twice a
medication. month; use a short-acting beta-agonist for relief
NHLBI Guidelines discuss the level of sever- of symptoms more than 2 days a week; and,
ity in three age groups: 0–4 years old, 5–11 years, because of their asthma, have some minor limita-
and 12 years and older. tions on the activities they normally perform.
In the 5- to 11-year group, most of the classi-
Intermittent Asthma fying elements are similar to the under 5 category
Note that the old nomenclature of “mild” no lon- except that nocturnal awakenings are increased to
ger prefaces intermittent. This is helpful in deal- between 3 and 4 a month. For lung function the
ing with people who believe that “mild” asthma FEV1 remains above 80%, but the FEV1 /FVC
is not a cause for concern. Individuals in this cat- ratio is reduced and is now only above 80%, and
egory should have daytime symptoms less than not the 85% permitted for intermittent asthma.
twice a week. Children under 4 should not wake Lung function measurements for persons aged 12
at night with symptoms, while older children and above are unchanged from the intermittent
should not wake more than twice a month. Short- category.
acting beta-agonist for the relief of symptoms
should be used less than 2 days a week, and there Moderate Persistent Asthma
should be no limitation on daily activities due to Here, there are daily symptoms, with night-time
asthma. awakenings three to four times a month, daily use
of a short-acting beta-agonist for relief of symp- • Persistent airflow obstruction between

toms, and some limitation or interference with exacerbations
daily activities. In the older groups, FEV1 will be• Emergency and hospital visits
between 60% and 80%, while the FEV1 /FVC • Wheezing apart from colds
ratio will be between 75% and 80% for the 5–11- • Evidence of sensitization to aeroallergens
year group and is reduced by 5% in the 12 and • Coexistent atopic dermatitis
over age group. • More than 4% peripheral blood eosinophils
• Proven food sensitization
Severe Persistent Asthma • Negative attitudes and misbeliefs about
These individuals will have continuous daytime medications
symptoms and frequent night-time awakenings, • Parental history of asthma
more than once a week for the under 5-year-olds • Psychosocial factors
and frequent to the point of almost nightly in • Certain demographic and individual
those over the age of 5; use a short-acting beta- characteristics
agonist several times a day; and be extremely
limited in their normal daily activities. For children under 3, the risk factors include
Lung function in the 5–11 age group will show two groups with any one of the following from
an FEV1 less than 60%, while the FEV1 /FVC ratio the first group [6]:
will be less than 75%. For those 12 and over, the
FEV1 will also be less than 60%, while the FEV1 / • Physician diagnosis of atopic dermatitis
FVC ratio will be more than 5% below normal. • Evidence of sensitization to aeroallergens
The FEV1 /FVC ratio declines normally with • Parental history of asthma
age, about 5% every 20 years. See Table 4.1. A
low FEV1 is indicative of current obstruction and and from the second group, any two of the
is a useful measure of the risk of exacerbation. following:
The FEV1 /FVC ratio is considered to be a more
sensitive measure of severity and control. • 4% or more peripheral blood eosinophilia
• Wheezing apart from colds
• Evidence of sensitization to foods
4.3.2 Risk Domain
After taking a history of symptoms, but prior
For all levels of severity in persistent asthma, to treatment, the individual’s asthma should be
exacerbations may occur more than twice a year. classified to the highest severity level at which
Children under 4 who have two or more exacer- any feature occurs. For instance, if there is a
bations that require oral corticosteroids (OCS) claim of infrequent symptoms, and an FEV1 80%
should be classified as having persistent asthma. of predicted, but the person further claims that
So too should children in whom asthma has not the asthma causes awakening about two nights a
been diagnosed but who have four wheezing epi- week, then the classification is moderate
sodes a year when risk factors are present. The persistent. Here, even though the first two param-
risk factors in this age group include: eters are indicative of mild persistent asthma, the
number of nocturnal awakenings is compatible
Table 4.1 FEV1/FVC ratios for different age groups with moderate persistent asthma and so that per-
Normal FEV1/FVC ratios son’s level of asthma is classified as moderate
Age in years Percentage persistent.
8–19 85% Specific elements for the classification of the
20–39 80% various severity levels are provided in Tables 4.2
40–59 75% and 4.3.
60–80 70%
Table 4.2 Classification of asthma severity for children aged 0 to 4 years

Level of severity—0 to 4 years
Impairment components Intermittent Mild persistent Moderate persistent Severe persistent
Symptoms ≤ 2 days/wk > 2 days/wk Daily Throughout the day
Night awakenings Nil 1–2/month 3–4/month > 1/wk
SABA use ≤ 2 days/wk > 2 days/wk Daily Several times/day
But not daily
Interference with normal activity Nil Minor limitation Some limitation Extremely limited
RISK domain exacerbations 0–1/yr ≥ 2 in 6 months requiring oral steroids
or 4 wheezing episodes/year lasting >1 day and risk factors
Table 4.3 Level of severity for ages 5–11 and ≥ 12 years

Level of severity—5 to 11 years, and 12 years and older
Impairment components Intermittent Mild persistent Moderate persistent Severe persistent
Symptoms > 2 days/wk > 2 days/wk Daily Throughout the
day
Night awakenings > 2/month 3–4/month > 1/wk but not Often 7x/wk
nightly
SABA use >2 days/wk > 2 days/wk but not Daily Several times/day
daily
Interference with normal Nil Minor limitation Some limitation Extremely limited
activity
Lung function 5–11 yrs FEV1 > 80% FEV1 > 80% FEV1 60–80% FEV1 < 60%
FEV1 / FEV1 /FVC > 80% FEV1 / FEV1 /
FVC > 85% FVC = 75–80% FVC < 75%
≥12 yrs FEV1 > 80% FEV1 > 80% FEV1 60–80% FEV1 < 60%
FEV1 /FVC FEV1 /FVC normal FEV1 /FVC ↓5% FEV1 /FVC
normal ↓ > 5%
Risk domain: Exacerbations 0–1/yr > 2/yr
Abbreviations: FEV1 forced expiratory volume in 1 second, SABA short-acting beta-agonist, FVC forced vital capacity,
wk week, yr year
4.4 Patterns of Asthma but they may be mild. With intermittent asthma,
night-time cough may continue after the worst of
When taking an individual’s history, it is impor- the episode is over. A great deal of care and
tant to discover their pattern of asthma. They may patience is required when taking the history, with
never have given this any thought, or noticed a specific attention being paid to the symptoms that
pattern; hence specific questions are needed. Is it occur between episodes.
seasonal? Is it workplace-related? How often
does an exacerbation occur? Do symptoms occur Frequent Intermittent
throughout the year? Are there nocturnal symp- Frequent intermittent asthma (Fig. 4.4) is com-
toms? All these will have an effect on both clas- mon at all ages. It is the most common single pat-
sifications of severity and treatment. A number of tern of asthma in the preschool child (usually
other confounding, perhaps confusing, issues are triggered by viral upper respiratory tract infec-
described next. tions), but is certainly not confined to this age.
Frequent intermittent asthma is characterized by
Infrequent Intermittent good health, full activity, and full participation in
Episodes may occur just once or twice a year in normal activities. This is interrupted by an abrupt
some individuals, but each one may be severe. deterioration, usually over a day or so, sometimes
Others may also have one or two episodes a year, over a shorter period of time. The symptoms are
or with exercise. If symptoms are disclosed

between episodes, then obviously management
of this type of asthma will differ from manage-
ment of those who have absolutely no symptoms
between attacks. Careful assessment and follow-
up are indicated because these patients, despite
their low level of symptoms, may have obstruc-
tion on spirometry; have persistent asthma; and
require long-term control therapy with inhaled
Fig. 4.4 Frequent intermittent asthma. (© The Asthma corticosteroids.
Education Clinic Ltd)
Intermittent with Interval Symptoms
A careful history is needed to identify people in
not unusual: some combination of chest tight- this category, who really have persistent asthma
ness, wheeze, breathlessness, or cough. Some but do not wish to admit that they have symptoms
have only one symptom, while others may have between episodes. Symptoms appearing only at
all of them. Many different events may cause the intervals may be accepted as being indicative of
episodes, but the usual ones are viral infections or good health, as they may be much milder than
exposures to environmental inhalation, seasonal those experienced with acute attacks (Fig. 4.5).
triggers, weather, and so on. There are often understandable reasons for a
If the history suggests frequent intermittent belief in intermittent asthma. For example, there
asthma, careful inquiry should be made of the may be a pet in the home, whose presence may
usual cause of the episode, the evolution, and the lead to chronic low-grade inflammation in the air
time taken to recover both with and without treat- passages and chronic mild asthma. Acute
ment. By “evolution” is meant the time course symptoms of asthma may follow an external trig-
between the first symptom, and onset of obvious ger such as a viral infection. The individual will
respiratory symptoms such as cough or wheeze, often want to believe that only the viral infection
and the period of time before there is severe causes the deterioration, but in truth it is syner-
breathlessness or distress. The number of epi- gism between the viral infection and the daily
sodes of asthma each year needs to be known. In allergen exposure that is to blame.
adults this may only be three or four, but in chil- People with asthma who deny the interval
dren, particularly preschool children, there may symptoms will be resistant to attempts to improve
be an episode every 2 or 3 weeks, each caused by their environment. Many individuals with interval
a different virus. symptoms accept without question limitations on
Those who are thought to have frequent inter- their lifestyle. Often they also accept and tolerate
mittent asthma should be asked in detail about
their health between episodes. This information
is critical for effective management. It is insuffi-
cient to accept a superficial account. Some may
say “I recover fully in six days and then feel well
until the next attack.” This may be true, but more
often it is only partly true. Following the improve-
ment after the acute attack, residual symptoms
are, by comparison, so mild that a state of subop-
timal well-being is accepted. Thus a full inquiry
of symptoms between attacks should be both
general and focused on the specific common Fig. 4.5 Intermittent asthma with interval symptoms. (©
symptoms, particularly those occurring at night The Asthma Education Clinic Ltd)
night-time disturbance as a normal part of life. If who might be of any age, require great care in
there is doubt about the history, the issue can usu- assessment and management. They present to the
ally be resolved with the use of a symptom diary healthcare system in many different ways.
kept over 2–3 weeks. For this to be successful, Sometimes, it will be because of a major deterio-
however, PEF must be measured with impeccable ration, but sometimes during a routine assess-
technique both morning and evening, together ment, they may complain of:
with treatment. Such individuals require continu-
ing long-term management. Scrutiny of their • Persistent night-time cough
environment may reveal preventable factors. • Difficulties with exercise
• Lack of energy, or frequent tiredness.
Chronic Persistent Asthma
This form of asthma does not fit the usual stereo- On examination, abnormalities may be
type of asthma, as there may be no external mark- detected, such as a barrel chest. FEV1 will be
ers of severity. Complicating the issue is the fact reduced most of the time, and PEF will show
that the NHLBI classification assumes and marked variation between morning and evening
includes exacerbations in all steps, thereby mak- (see Fig. 4.7). An alert healthcare provider will
ing those individuals with few or no exacerba- notice the clues and explore their history in detail.
tions difficult to classify. Typically, in this form Individuals with chronic persistent asthma
of asthma, there are: may not realize how severe their symptoms are
(or have been) until they start to improve and they
• No episodes of severe recurrent wheezing experience a feeling of well-being.
• No recurrent emergency department visits Each person’s environment must be rigorously
• No recurrent admissions to hospital. scrutinized for possible triggers, and improve-
ments to that environment must then be recom-
In those with chronic persistent asthma, there mended. Environmental measures almost always
are acute exacerbations from time to time need to be supplemented with inhaled corticoste-
(Fig. 4.6), but symptoms are usually daily in roids. Indeed, inhaled corticosteroids for these
nature and consist of cough and dyspnea. In fact individuals often need to be of a high dose and, in
their symptoms occur usually at night as well as some cases, to include systemic corticosteroids.
by day. Symptoms may be minimized by avoid- At this stage it is clear that a fuller evaluation is
ance of physical activity and may also be ignored needed, including assessment of immune func-
or denied.
Individuals with chronic persistent asthma,
who have symptoms every day and night and
Fig. 4.6 Chronic persistent asthma. (© The Asthma Fig. 4.7 Daily variations in peak flow reading. (© The
Education Clinic Ltd) Asthma Education Clinic Ltd)
tion and a determination whether or not allergies Recurrent Atelectasis

are relevant. BAL may be needed to completely Mucus production is part of asthma. In all indi-
describe the phenotype. In the past the need for viduals with asthma, there is airway inflamma-
long-term follow-up, detailed education on tion, contraction of muscle (resulting in narrowing
asthma, and the need for encouragement to real- of the airways), and also mucus production that
ize their personal potential for well-being were increases the airway obstruction.
all recognized. Now it is known that one of the Mucus plugs may block airways and thereby
newly available, novel therapies may be the best lead to collapse of small areas of the lung. This
hope for improvement. collapse can be seen on X-rays. The X-rays are
however difficult to interpret, as the shadow due
Persistent Asthma in Infancy to collapse of part of the lung (atelectasis) is not
Wheeze in infancy is both difficult and confusing. always easily distinguishable from the shadow
For many years, physicians were reluctant to diag- caused by pneumonia. Apart from the diagnostic
nose asthma in infants and instead used other confusion, once the asthma is recognized there
names such as wheezy bronchitis, obstructive are no differences in management from other
bronchitis, bronchiolitis, and so on. However, there individuals with asthma. Children with atelecta-
is now a growing realization that asthma does occur sis of the middle lobe should be investigated for
in infancy. Having said that, a thorough analysis is asthma.
needed, as the differential diagnosis is wide.
The approach in terms of environmental pro-
tection is the same as for asthma occurring at 4.4.1 Important Factors
other ages. Medications are used in management, Contributing to Severity
but the response in infants is not quite as com-
plete as in older children. There are many reasons 4.4.1.1 Phenotypes of Asthma
for this, including the airway anatomy and differ- While it has long been known that asthma is a
ent defense mechanisms (see Chap. 2). However, very heterogeneous disorder, it is now becoming
in a substantial proportion of infants, symptoms clear that this very heterogeneity means that dif-
will gradually improve and may even disappear ferent treatments are required for different phe-
by school age. notypes of asthma. It can no longer be assumed
The concepts of early-onset wheeziness that “one treatment fits all.” As noted in Chap. 1,
(before 3 years) and late-onset wheeziness (after there are multiple endotypes, each with a specific
3 years) were developed by the Tucson group pathobiological mechanism, and an understanding
[12]. Children with early-onset wheezing who of these would be very useful in guiding treat-
continued to wheeze after age 6 were found, usu- ment. Presently, the endotypes cannot be outlined
ally, to have a family history of asthma and raised in enough detail, and therefore phenotypes,
IgE. Children whose wheeze remitted by age 6 which can actually be seen, are used instead. The
did not have the same history of allergic features, goal is to seek “treatable traits” within the pheno-
but did have narrow airways as infants. Only in type, and ensure that the investigations are
retrospect can those infants whose “asthma” per- expanded to include them. As different pheno-
sists be distinguished from those whose symp- types may have identical symptoms, accurate
toms disappear. characterization of the phenotype requires further
At this time, there are no routinely available investigation in those with severe asthma.
diagnostic tests for use with children of this age. One type of investigation of severe asthma
It is not possible to do an FEV1 or PEF. The clini- requires understanding of the type of airway
cal response to bronchodilators is helpful if it inflammation, and this is where induced sputum
occurs, but even when the response is slow, there or BAL is so important [13]. The most common
may still be asthma. Many of the diagnostic con- phenotype is eosinophilic, related to the produc-
siderations are detailed later in this chapter. tion of type II cytokines. The allergic phenotype
is the stereotypical phenotype of eosinophilic extreme activity, perhaps additionally in the

asthma, and in this situation avoidance of triggers cold, have symptoms only at levels of exercise
is very important. Some of the ways of doing this never reached by the vast majority of the
and some of the difficulties are described in population.
Chap. 6. Many of those with this form of asthma Individuals with asthma should be asked how
will benefit from the use of omalizumab. they are affected by exercise. The questions
Another form of eosinophilic asthma is the need to be specific and to consider all forms of
non-allergic type. People with this form of physical activity, not just intense formal exer-
asthma have later age of onset, nasal polyps, and cise. Symptoms may include chest tightness,
aspirin (ASA) sensitivity. Such individuals may shortness of breath, wheeze, or cough coming
benefit from mepolizumab. on after a few minutes of exercise and which
The non-eosinophilic form of asthma is usu- may resolve with rest or with a bronchodilator.
ally associated with neutrophils, and clinical For some, fatigue is the main complaint. Some
manifestations tend to be those of severe asthma children complain of stomachache. EIA is
with a poor response to corticosteroids. At pres- sometimes followed between 3 and 9 h later by
ent, there are no easy solutions for such individu- bronchospasm. This is the late phase response,
als. It is really important that when treating a and the severity of the initial response is directly
person with non-eosinophilic asthma, care be correlated to the risk of a late phase response
taken to avoid side effects. In other words, the [18, 20, 21].
dose of corticosteroids should not be escalated Most individuals with asthma will find that
beyond a level that would be helpful. their tolerance for exercise improves as they take
Another series of investigations are those used steps to improve their overall asthma control. For
to establish the genotype. At present, over 60 those few individuals with a strong interest in
genetic loci have been associated with asthma intense exercise and competitive sports, help can
[14]. Identifying clusters of phenotypic/geno- also be provided, although the first step in help-
typic correlations is one of the most important ing them is to improve their asthma control in
areas of research taking place today. It will allow general.
recognition of asthma variants and in turn will Thus it is important to recognize that there are
drive the development of novel interventions. two groups for whom exercise is a problem: those
for whom exercise is the only manifestation of
4.4.1.2 Exercise-Induced Asthma asthma and the vast majority who have exercise
It is not clear that this commonly exists as a asthma as one component but who also have
separate entity. Many writers talk about significant other symptoms. The management

exercise-induced asthma (EIA), but in reality approach differs in each case.
most individuals with asthma have problems When exercise symptoms alone are present,
with exercise at some time or other. The symp- asthma management should concentrate only on
toms produced are probably the result of loss of the exercise. This topic is dealt with in more
fluid in the airways [15–17] and airway cooling detail in Chap. 8.9 Competitive Athletes, as exer-
[18] due to dry air reaching the lower airways. cise bronchospasm without asthma can be a
This in turn is due to the large tidal volume major problem in this group (and also in those
overwhelming the ability of the nose and upper who just want to exercise hard). When treating
airway to humidify the air. Only a few persons exercise symptoms as an isolated problem, inha-
have symptoms with exercise alone; many more lation of albuterol or formoterol a few minutes
have exercise-related as well as other asthma before exercise will help. If there are other sig-
symptoms [19]. They may believe that they have nificant symptoms of asthma, general treatment
problems with exercise alone, paying little measures directed at improving the asthma might
attention to the other symptoms of their asthma. reduce the frequency and severity of exercise
Some athletes, such as those in sports requiring symptoms.
4.4.1.3 Nocturnal Asthma • Significant daytime exposure (to a substance

Symptoms of asthma are more common at night encountered at work or in the home) which
than in the daytime. Even those whose condi- results in a late reaction.
tion is stable will, under close questioning, • Allergens/irritants in the bedroom, such as a
admit to frequent nocturnal symptoms. Only a pet (Note that these may pervade all areas of
small number will have asthma only at night; the home 24 h/day.)
nevertheless, a full evaluation should be per- • Untreated sinusitis.
formed of their night-time symptoms. Night- • Gastroesophageal reflux.
time symptoms affect daytime performance at • Unrecognized sleep apnea.
work and at school. • Untreated allergic rhinitis (itself a contributor
Many different aspects of body function to sleep apnea).
exhibit a normal diurnal variation. For the lungs
pulmonary function tends to be lower in sleep Some asthma triggers, such as house dust
than when awake. The day/night variation is mites and dander from pets in the home (both of
shown in PEF that is lower in the morning than which are found throughout the house, including
the afternoon. Many factors present in every per- the bedroom), have an effect on overall control of
son contribute to increased symptoms at night, the asthma, and not just on night-time asthma.
such as: See Fig. 4.8.
With the older adults, it is important to ensure
• Decreased cortisol that cardiac disease or some other problem is not
• Decreased adrenaline the cause of the symptoms. The diagnosis and
• Decreased body temperature assessment of nocturnal asthma are done by
• Increased vagal tone. direct questioning, supplemented by morning
and evening PEF for some days.
Most persons with asthma will tend to experi- Many of the factors surrounding night-time
ence symptoms at one time or another. The symp- asthma are similar to those for exercise-induced
toms will vary and will include: asthma. For all, a careful history will include a
description of night-time symptoms. Following a
• Coughing, or any symptom, sufficient to lead review of all the data, it will be possible to distin-
to arousal with a rapid return to sleep guish the small group of those with symptoms
• Coughing without disturbance of sleep only at night from the much larger group who
• Asthma severe enough to require drug have symptoms at night as part of overall poor
therapy.
A number of authors [11, 22] discuss noctur-

nal asthma and describe specific treatment,
much of it focusing on the bedroom. In reality,
many of the causes of night-time asthma are
triggers to which the individual has been
exposed during the day. Thus night-time asthma
is often a manifestation of overall suboptimal
control. Given that pulmonary function is worse
at night, those with suboptimal control may
manage by day, with symptoms becoming mani-
fest only at night [11].
Individuals with asthma may have reversible
factors that will reduce the need for high-dose Fig. 4.8 Frequency of asthma and triggers at different
medication. Examples are: ages. (© The Asthma Education Clinic Ltd)
control of their asthma. Nocturnal symptoms are viral infections in the initiation of symptoms.
not often reported to healthcare professionals Sometimes complaints about asthma are due to
because they are perceived as being a “normal” symptoms better attributable to other allergic dis-
part of having asthma and hence of no concern. orders. Hence, the educator should determine
Frequent nocturnal symptoms are not recognized whether they have much trouble with allergic rhi-
as an indication of severity and poor asthma con- nitis or eczema and then provide appropriate
trol [22]. help.
In cases where there is overall poor control of Common allergens are house dust mite, par-
asthma and symptoms occur at night as well as ticularly in warm humid areas, and cat and dog
by day, effective environmental control measures allergen in all areas. In drier areas, Alternaria
need to be taken. Adherence, together with appro- is a far more common allergen. Those with pol-
priate drug therapy, needs to be ensured. Daytime len allergy tend to have rhinitis rather than
symptoms will generally improve first, but as asthma.
general control improves, night-time symptoms When attempting to identify possible aller-
will also diminish and perhaps disappear gens in persons with asthma, answers to the fol-
completely. lowing important questions should be obtained:
For a small number of individuals however,
night-time symptoms will persist despite all rea- • Does a seasonal variation in symptoms occur?
sonable measures and despite good control by • Do symptoms vary with the time of day?
day. They will require specific further strategies. • Do allergies occur at one place and not at
These might include extremely rigorous attention other places?
to the care of the bedroom; exclusion of medical • Do symptoms occur during one activity but
conditions such as gastroesophageal reflux, not during others (e.g., do they occur when
which may lead to night-time problems; and use visiting friends with pets?)
at night of specific drug therapy such as long-
acting beta-agonists that are readily available in The answers will help narrow the search for
combination devices with inhaled corticosteroids potential allergens.
(ICS).
4.4.1.4 Allergies, Asthma, 4.4.2 Occupational Asthma

and Seasonal Changes
Four out of five people with asthma have aller- Occupational asthma is an unfortunate reality
gies—usually Type 1 allergy, which leads to [25]. It may cause increased symptoms in per-
overproduction of IgE. The word “allergy” refers sons who already have asthma and may lead to
to this reaction, and individuals with a genetic symptoms of asthma in those who had none pre-
tendency to produce IgE antibodies are called viously. In the latter group, once asthma devel-
atopic. Individuals who are atopic tend to have ops, symptoms will be provoked by nonspecific
not only asthma but also other diseases with an factors such as exercise, cold air, and respiratory
allergic component including allergic rhinitis, infection.
hay fever, and atopic dermatitis commonly called There is a wide variation in the time course of
eczema [23]. occupational asthma, depending on the sub-
The fact that an association exists between stance, the dose of exposure, and individual pre-
allergies and asthma does not imply that allergies disposition. This can be from a few days to many
are necessarily causal. However, the strong asso- years. One of the characteristic features of the
ciation between the development of allergies and history of persons with occupational asthma is
the development of asthma suggest that they play that symptoms occur while at work or just after
some role in asthma [24]. Such a role might be to work and remit while away from work, whether
act in combination with other factors such as for a weekend or an extended vacation.
Many of the agents that cause occupational been, and is still, used extensively in the medical
asthma are allergens, while others are irritants. literature, it does not convey the fact that there
The more common substances involved are iso- are levels of acute asthma. Those with severe
cyanates (used in the manufacture of polyure- acute asthma present a characteristic clinical pic-
thane), animals, flour, various foods, and solder. ture and require rapid assessment. They are
The causes of occupational asthma will vary extremely short of breath; are unable to say full
from one geographic region to the next, and edu- sentences, sometimes not even full words; have
cators must be aware of those substances that are extreme chest tightness; and are using accessory
prevalent in their area or region. muscles of respiration. As the attack increases in
In taking the initial history of an individual severity, cyanosis becomes evident, and they may
with asthma, it is important to ask about the occu- become confused and drowsy. For these persons,
pation and about the time course of symptoms. oxygen saturation (using a pulse oximeter), heart
These may point to an occupational cause. rate, and respiratory rate should be measured
The implications of occupational asthma are immediately. Blood pressure should be checked
very significant. Though the asthma needs to be to see if pulsus paradoxus is present. Wheeze
treated, the person will almost certainly have to may not be heard in the most severe of attacks,
change occupation. Given the potential economic but auscultation should still be done. Breath
and personal effect of this diagnosis, further sounds may be faint, but the healthcare provider
investigation—and confirmation—should be should determine that they are symmetrical.
undertaken by a specialist in the area of occupa- It is difficult to quantify severe acute asthma.
tional respiratory disease. The components listed above neither develop
simultaneously nor at the same rate. They also
relate poorly to one another [26, 27]. Individuals
4.5 Life-Threatening Asthma with severe acute asthma demand immediate
management, even as the assessment is
4.5.1 S
evere Acute Asthma (Status proceeding.
Asthmaticus) A population-based study [28] of individuals
with life-threatening asthma and who required
While many people with asthma talk of sudden assisted ventilation concluded that they were
deterioration in their condition, closer scrutiny mainly young adults with onset of disease in
may reveal that the deterioration is not quite so childhood and with frequent symptoms. They
sudden. They may have gradual onset of deterio- used bronchodilators extensively, felt vulnerable,
ration, but did not realize they are deteriorating and had stress. It is noteworthy that these subjects
until they have lost a considerable amount of pul- were exposed to tobacco smoke and pets.
monary function. Such individuals can be identi- The pattern of recovery is bimodal, with the
fied with careful monitoring of symptoms and majority clearing within 2 h. However, up to a
with careful twice-daily monitoring of peak flow quarter have poor short-term outcomes, and
(see Fig. 4.7). With these measures, the slow 15–17% relapse over the 2 weeks after presenta-
deterioration will be noted, and corrective action tion. This variability has led to the suggestion
can be taken at the start of peak flow deteriora- that acute asthma should be categorized by out-
tion. A peak flow reading of less than 50% indi- come rather than by presentation [26].
cates a severe exacerbation [4]. If they can be During the recovery phase, a review should be
convinced that deterioration is not sudden, but conducted of the sequence of events that pre-
predictable, and they then comply with treat- ceded the initial presentation with severe acute
ment, the outlook for asthma control will be asthma. Commonly, there is delay in seeking help
excellent. in an acute episode, and the recovery phase gives
Severe acute asthma refers to a life-threatening the educator an opportunity to reaffirm the need
episode. While the term “status asthmaticus” has for a proactive approach to an increase in symp-
toms. At the same time, a complete assessment of with relevant and important medical information
all aspects of the case, including: including contact names and phone numbers.
• A detailed environmental assessment of the

individual’s home and workplace 4.6 Differential Diagnoses
• Knowledge of appropriate medication admin-
istration techniques 4.6.1 Wheeze and Lung Disease
• Inventory of appropriate available reliever
medication Healthcare providers often quote the saying “All
that wheezes is not asthma.” While this is an
should be done to characterize the asthma and the important warning to bear in mind, it, like all
individual’s needs as completely as possible. A generalizations, has its limits.
comprehensive chronic management plan (an Some healthcare providers take this statement
asthma action plan) should then be devised, and a so much to heart that they do their best to avoid
strategy for early intervention in further acute the diagnosis of asthma and instead use all sorts of
episodes should be developed at the same time. other phrases (such as “reactive airways disease”
and others mentioned earlier) or consider all sorts
of other diagnoses. For this reason, much recent
4.5.2 B
rittle Asthma, Catastrophic educational effort has been directed towards
Asthma reminding healthcare providers that many (though
not all) cases of wheeze are caused by asthma and
Brittle asthma [29, 30] is a term used for persons that they should not be afraid to diagnose asthma
whose asthma is difficult to control despite use of if the symptoms fit. “Reactive airway disease”
the best available measures. Those with brittle (RAD) and the other euphemisms serve only to
asthma may present with severe acute asthma, cloud, rather than clarify, the problem.
but not all episodes of severe acute asthma can be Earlier, measurement of airway reactivity was
described as being brittle. Individuals with brittle described as an important way to confirm a diag-
asthma have chronically poor control, episodic nosis of asthma (see Chap. 3). While this is true, it
exacerbations, and persistent airway obstruction cannot be assumed that airway reactivity automat-
despite their use of high-dose inhaled corticoste- ically indicates asthma. Many other chronic lung
roids [31]. diseases have airway reactivity as one of their fea-
It has been suggested that there are two types tures. For example, COPD (chronic obstructive
of brittle asthma [32]. Type 1 has low airflow and pulmonary disease), also known as chronic
seems to be associated both with continued expo- obstructive lung disease (COLD), is one such
sure to allergens known to cause sensitization group of diseases. It includes chronic bronchitis
and with significant psychosocial factors. The and emphysema; chronic lung disease in infants;
approach to Type 1 brittle asthma needs attention cystic fibrosis; and many other illnesses. As noted
to the many different factors, particularly atopic earlier, the Lancet Commission points out that
status [33] and psychosocial factors [34]. recent evidence does not seem to support the tradi-
Type 2 brittle asthma, otherwise known as tional sharp differentiation of asthma and COPD. It
catastrophic asthma, is associated with very sud- is possible but rare to have asthma with minimal or
den attacks. Just as with Type 1, Type 2 brittle no reactivity and to have airway reactivity without
asthma also demands careful and full assess- asthma. Nevertheless, airway reactivity and
ments; and here, too, the healthcare provider asthma are closely related, but there is no one rec-
must attempt to optimize treatment. Type 2 indi- ommended way to measure reactivity [35].
viduals may need to restrict some activities, such By now, it should be obvious that the term
as wilderness travel, and should always carry “reactive airways disease” has no place in the
identification such as a medical alert bracelet, health professional’s vocabulary. The title of a
paper, “Reactive Airways Disease”, A Lazy Term Some of the COPD/asthma confusion occurs in
of Uncertain Meaning That Should Be Discarded older adults because asthma is one of the contrib-
[36], summarizes these views admirably. uting factors that may lead to development of
Wheeze is a noise produced by narrowing of COPD in persons who are confirmed smokers [37,
the airway, and wheeze (and reactivity) occurs as 38]. For example, someone with asthma, who is or
a major component of many diseases in child- has been exposed to smoke or to environmental
hood including: pollution, may also develop chronic obstructive
lung disease with or without emphysema. When
• Cystic fibrosis such a mixed picture is present, the airways will
• Chronic lung disease of prematurity show reactivity, and frequently there is wheeze
• Esophageal reflux (although evidence suggest with infection. There may be a partial response to
this is overdiagnosed and overtreated in environmental protection and asthma treatment.
infants) Dyspnea on exertion and wheezing are common
• Bronchiolitis of infancy in older adults [39–41]. Dyspnea is independently
• Inhaled foreign body associated with chronic bronchitis, a common
smoking-related lung disease that is accompanied
Wheeze in adult can be heard in: by chronic cough and sputum production.
The symptoms of emphysema include chronic
• Congestive heart failure cough, chronic phlegm, dyspnea on exertion,
• Chronic obstructive lung disease, including attacks of dyspnea with wheezing, and weight loss.
emphysema, and chronic bronchitis Emphysema is associated with cigarette smoking,
• Lung cancer but a person has to have smoked for many years
• Esophageal reflux and before symptoms appear [42]. Both chronic bron-
• Laryngospasm chitis and emphysema are chronic lung diseases.
COPD caused by smoking may respond to anti-
This is a partial list of diseases that can pro- inflammatory medications, and this result tends to
duce wheezing. Anyone with these diseases may obscure the distinction between asthma and other
wheeze, and bronchodilators may be prescribed forms of obstructive lung disease [1].
for them, but they do not have asthma. Further,
the mechanisms of wheeze may vary in these dif-
ferent diseases. Some people may have some 4.6.3 Hyperventilation
contraction of the smooth muscle, and often there
will be edema of the airway wall. More com- Rapid or inappropriately deep breathing is
monly there will be physical distortion of the air-
called hyperventilation. Hyperventilation is one
way, with areas of irregularity due to scarring and
component of a panic attack. It may be triggered
loss of elastic tissue. There will also be secretions
by fear, and one of the fears might be of an
in the airway. While bronchodilators will be pre- asthma attack; in fact, many symptoms of panic
scribed, the response in these diseases will proveattacks can be mistaken for asthma, including
much slower and less complete than in asthma. dyspnea, tachycardia, chest pain, and rapid or
noisy breathing. As these can also be present in
asthma, careful attention must be paid to all
4.6.2 COPD and Asthma symptoms in order to differentiate between
asthma and panic attacks [43].
Many people find these terms confusing and The reason for the confusion is that hyperven-
might use them interchangeably. Even with clear- tilation, because it delivers large amounts of non-
cut and certain diagnosis of COPD, there may humidified air to the lower airway (similar to
still be some improvement with bronchodilators. exercise-induced asthma), may trigger broncho-
This minor degree of reversibility does not mean spasm and either cause an asthma episode or
that asthma is the primary diagnosis. make it worse. It is not easy to distinguish
between dyspnea and hyperventilation, and they

may occur together.
Misunderstanding of symptoms can result in
overtreatment of asthma when both are coexis-
tent. This can become a vicious circle where
panic leads to hyperventilation which results in
asthma which in turn causes further panic.
Alternatively, the circle can work in reverse,
starting with an asthma episode that then triggers
a panic attack [44]. Thus it is very important that
the degree of anxiety be understood in someone
with asthma and that when there is acute deterio-
ration, attention be paid both to the fear that
accompanies the attack and to the narrowing of
Fig. 4.9 Peanut in airway. (© The Asthma Education
the airway [45]. Clinic Ltd)
4.6.4 Vocal Cord Dysfunction (VCD) is most common in toddlers, but can occur at any
age. In adults, bronchial cancer or adenoma either
In vocal cord dysfunction [46–49], the vocal cords in or around the air passage can cause both
close during inspiration (paradoxical closure), wheeze and cough together with airway obstruc-
which leads to wheezing and dyspnea. VCD is not tion. See Fig. 4.9.
a structural but a functional disorder of the airway.
While it has a superficial similarity to asthma, it
does not improve with asthma treatment. Case Study
Common triggers include upper respiratory
infections (URIs), tobacco smoke, fumes, odors, Dean Smith has brought his 10-year old
talking, singing, emotional upset, exercise, and granddaughter to see you and says that she
stress. During an episode, stridor or wheezing is having an asthma attack. She is breath-
and use of accessory muscles during inspiration less and frightened. Upon questioning you
may be seen. The symptoms reported often discover that she has not been diagnosed
include wheeze, cough, dyspnea, tachypnea, a with asthma and that she went to the mall
choking sensation, chest pain, stridor, voice with her friends, against her parent’s
changes, and difficulty in speaking [50]. wishes. How do you respond?
Pulmonary function tests are normal both Check for other symptoms of asthma.
after an episode and during asymptomatic peri- Fear can speed up breathing and this in
ods [51]. A diagnosis of vocal cord dysfunction itself can trigger an asthma attack.
needs to be considered in a variety of situations, However, she may not have asthma. She
including “asthma” that is unresponsive to treat- needs to slow her breathing. It is essential
ment. It is generally confirmed by an experienced she continue a pattern of slow, deep breath-
otolaryngologist through an examination of the ing till she is calm and in control. It is
vocal cords. VCD and asthma may coexist. important to proceed simultaneously with
calming the child and the grandparent and
to obtain expert medical advice either at
4.6.5 Bronchial Obstruction ED or from the family healthcare provider.
While this is happening, offer to contact the
Inhaled foreign bodies can cause airway obstruc- parents.
tion and produce both cough and wheezing. This
4.7 ime Course of Events

T During exercise, hyperventilation takes place,
in Asthma and air tends to be cooler and drier than that usu-
ally present in the respiratory tree.
This is usually taken to mean the pattern or mani-
festation of asthma in the minutes, hours, or days
after a specific exposure to a trigger. 4.7.2 Response to Allergens
Many factors affect this time course, among
them being the intensity of the exposure and the Allergen exposure has been described under the
dose involved. For example, a small amount of section on allergy. If, for instance, there is expo-
smoke may produce mild irritation, whereas a sure to pollen that impacts on the nasal mucosa,
large amount may produce a major reaction. In there may be immediate symptoms such as sneez-
addition, some individuals are characteristically ing or coughing; if it impacts in the lower respira-
much more sensitive to external agents than oth- tory tract, it may also cause wheeze [23]. This
ers and have very “twitchy” airways. This latter may be followed by a late reaction—the dual
factor is enhanced if pulmonary function is poor response, 6–12 h later, with further severe symp-
before the exposure and the asthma is severe. toms of wheeze, cough, and dyspnea. The late
Any discussion on the time course of asthma reaction may manifest itself during the night, and
is based on the background of a diurnal variation this can be mistaken for nocturnal asthma. Thus it
in pulmonary function. In an earlier section, peak should be remembered that daytime exposures
flow was described. Peak flow is typically lowest should also be scrutinized whenever problems
at 4 a.m. and best at 4 p.m. Thus, in most indi- occur at night time.
viduals with asthma, peak flow is low in the
morning and rises towards the evening (see
Fig. 4.7). As the asthma becomes well-controlled, 4.7.3 Response to Viral Infection
the morning and the evening levels show little
variation from one to the other. A viral infection is also an exposure, but of a dif-
This section presents the time course of three ferent sort. Upper respiratory symptoms occur at
typical situations: response to exercise; response the onset of viral infection. Then in those with
to allergens; and response to viral infection. As asthma, lower respiratory symptoms (such as
mentioned earlier, all three are extremely com- wheeze) begin, usually after 1 or 2 days of the
mon in asthma and can place major restrictions upper respiratory symptoms (runny or blocked
on quality of life. nose and later coughing). Marked inflammation
occurs in the lower respiratory tract, together
with increased irritability of the airways. This
4.7.1 Response to Exercise continues for some days before gradually subsid-
ing. If untreated, symptoms may occur at night
Exercise-induced asthma usually occurs within for 2–3 weeks after the episode [52, 53].
minutes of the onset of vigorous activity, and air- The preceding description, which is summa-
flow reaches its lowest point about 5–10 min after rized in Fig. 4.10, offers a conventional look at
the activity stops. If mild, resolution occurs spon- the time course of asthma. If a long-term (or
taneously over the next 20 or 30 min. A late phase “life”) view is taken of the asthma, however, a
may or may not occur; if it does, it is uncommon different picture emerges, and one that is worth
and usually mild. If exercise is repeated, there is exploring briefly. When considering changes
often a refractory period that lasts for about 2 h throughout life, rather than just a particular inci-
after vigorous exercise. Thus, exercise-induced dent, it can be stated that the process of asthma
asthma is due mainly to smooth muscle constric- often begins in infancy. At that time (see
tion and usually results from the loss of heat or Fig. 4.11), there may be frequent acute attacks
water, or both, from the lung during exercise. for several years, followed by an evolution over
Fig. 4.10 Process beginning with exposure to triggers and ending in the development of asthma. (© The Asthma
This has been specifically noted in young chil-

dren, particularly when there is wheeze associ-
ated with respiratory infection and, following the
episode, no evidence of ill health. While a par-
ticular problem with young children, it should be
noted that under-diagnosis may occur at any age.
Diagnostic problems are best considered sepa-
rately for each age group, as the situations are
different.
4.8.1 Age-Related Asthma

Fig. 4.11 Generalized fluctuation in asthma severity over
the years showing periods both of improvement and dete- 4.8.1.1 Less Than One Year of Age
rioration. (© The Asthma Education Clinic Ltd) Diagnostic problems are more common here than
through the rest of childhood. Major conditions
some period of time. In some cases, this evolu- to consider include:
tion leads to remissions while in others, to persis-
tent symptoms. Asthma may then take one of the • Other causes of lower airway obstruction such
forms described earlier, such as chronic persis- as infectious disorders including viral bron-
tent or episodic with interval symptoms. chiolitis, or genetic disorders such as cystic
Even children with persistent asthma through- fibrosis
out childhood may show some degree of remis- • Bronchopulmonary dysplasia (an aftermath of
sion in adult life. However, this initial adult prematurity)
remission may be followed by a relapse in later • Gastroesophageal reflux (with or without
adult life. While the most common time for aspiration)
asthma to begin is infancy, it may start at any • Cardiac failure
time, including adult life, and in such a case, it • Vascular rings or slings
may be chronic persistent asthma. Even in such a • Congenital anomalies of the lung.
situation, there may be remission over time.
Viral bronchiolitis is extremely common.
Most children will have this illness in the first
4.8 Diagnostic Problems year of life, with the most common single viral
in Asthma pathogen being the respiratory syncytial virus
(RSV). In the acute phase of the illness, there will
Individuals of all ages with asthma usually look often be wheeze which resolves. However many
well, unless the asthma is particularly severe. As infants with viral bronchiolitis have recurrent
mentioned earlier, the physical examination may wheezing for 2–3 years after the acute illness.
be negative and a correct diagnosis overlooked. While this may be more likely if the parents are
Under-diagnosis is a major problem in asthma. allergic, and if there is exposure to smoke or pets
in the home, it can also occur in persons with Under the age of 1 year, asthma probably
small lungs or relatively narrow airways. accounts for about one-third of the causes of
Occasionally, it will not be possible to determine wheezing, and the others are accounted for by
precisely why there is wheezing. some of the diseases mentioned (and by many
The long-term outlook for wheezing caused others not mentioned).
by viral bronchiolitis is very good. Treatment A family history of asthma and the presence
similar to that for asthma is often used, following of infantile eczema (atopic dermatitis) are impor-
which only a small proportion of children will tant predictors of asthma, but not by themselves
continue to wheeze. Many viral infections lead to critical diagnostic features.
airway obstruction and wheezing, but generally With upper airway obstruction (UAO), stri-
tend to have good outcomes. dor is likely to be present in addition to or
Infants with cystic fibrosis often look healthy. instead of wheeze, but not always. UAO may be
There may be no malabsorption, but they may caused by:
show evidence of lung disease and wheezing
with viral infection very similar to viral bronchi- • A foreign body
olitis or to asthma. • A vascular ring
Bronchopulmonary dysplasia is a disease of • Laryngomalacia
the lung which develops in extremely premature • Tracheomalacia
babies who required complicated neonatal care, • A tumor
commonly with ventilation and supplementary • Laryngeal web
oxygen. These infants often wheeze, especially • Tracheal stenosis/bronchial stenosis (narrow-
with viral illnesses. This situation may remain ing of the trachea/bronchi).
with them for many years, and while they proba-
bly do not have asthma, technically speaking, If the family of an infant under 1 year of age
management may be very similar to that for is being seen for education or counseling, the
asthma. family should consult their healthcare provider if
Gastroesophageal reflux is common in the following symptoms are observed in the
infancy. On some occasions, it may cause aspira- child:
tion and wheezing; at other times, it may not Failure to gain weight
cause aspiration and the wheeze may be due to a Symptoms starting in the first few days/weeks
coincidental illness such as viral bronchiolitis or of life
asthma. There is concern, at least in infancy, that Symptoms every day, with little variation
“Non-specific symptoms such as irritability, within or between days
vomiting, and back arching during the infant Any blueness or extreme distress
period are often attributed to gastroesophageal Frequent vomiting.
reflux” without supportive diagnostic tests. The
concern is compounded by prescription of acid
suppressant medications in the face of numerous
Case Study
studies showing no benefit [54].
Most congenital anomalies of the lungs are Anna Emms has brought her 3-year-old to
identified nowadays in utero, some at birth, and a see you. She says that he has been wheez-
small number later in life. In general, when chil- ing on and off for the last 3 days and she
dren under 1 year of age present with respiratory wonders if he has asthma. The child does
problems, a chest X-ray should be ordered. This not appear to be in any distress. What
may show other congenital anomalies that will should you do?
require more investigations. Check for any other symptoms that
If recurrent wheezing continues beyond the could suggest asthma.
age of 1 year, the most likely cause is asthma.
sive and active smokers, and individuals may be

1 . What is his breathing rate? unwilling to provide a clear history.
2. How often does he wheeze? While vocal cord dysfunction (VCD) presents
3. Does it occur at any particular time of much like asthma, it will respond poorly to medi-
day or during any activity? cations. Treatment consists of speech therapy or
counseling. VCD may also occur in persons with
Suggest that she see her child’s physi- asthma, and this may explain why such cases par-
cian immediately. In children this age, tially respond to treatment.
obstruction of a large airway by a foreign
body can be the cause of wheezing. This 4.8.1.5 Twenty-Five to Thirty-Five Years
may need urgent attention. Children can Asthma is the most common cause of cough and
die from inhaled unrecognized foreign wheeze.
bodies, especially organic ones. Sometimes, Other causes include:
inert substances—such as plastic toy
parts—can be present for a long time before • Post-infectious cough
they are identified and removed. • Postnasal drip
• Smoking
• Occupational lung disease
• Gastroesophageal reflux
4.8.1.2 One to Five Years • Chronic bronchitis (COPD)
In this age, asthma is the most common cause of • Drug-induced wheezing
cough and wheeze. If persistent, major differen- • Alpha 1-anti-trypsin (AAT) deficiency
tials will include all of the conditions noted for becomes obvious between 20 and 50 years old
children under 1 year. However, an inhaled for- and may present as wheeze and be misdiag-
eign body—peanuts, plastic beads, small toy nosed as asthma.
parts, and so on—is the most common other
cause of cough and wheeze. 4.8.1.6 Thirty-Five to Sixty Years
In addition to those conditions considered in
4.8.1.3 Five to Twelve Years the differential diagnosis in all the preceding
Asthma is the most common cause of cough and age groups, other disorders now appear,
wheeze, though these may also be seen after a including:
number of infections.
• Chronic bronchitis and emphysema
4.8.1.4 Twelve to Twenty-Five Years • Congestive heart failure
Asthma remains common. Items to consider • Pulmonary embolism
include: • Cough secondary to medications, such as ACE
(angiotensin-converting enzyme) inhibitors
• Post-infectious cough • Bronchial cancer.
• Smoking
• Vocal cord dysfunction. 4.8.1.7 Sixty Years and Above
Differential diagnosis should be as before, but in
Some individuals will, at some stage in their all likelihood, there will be more than one disease
life, have a cough that persists for many weeks present, and numerous medications will often be
following a bout of viral pneumonitis. While this in use. Dyspnea on exertion and a low FEV1 is
can be difficult to distinguish from asthma, the generally linked to cardiovascular disease; as a
pattern occurs only once and does not recur. result, airway obstruction may remain undiag-
Smoking may be a significant cause, both in pas- nosed [40, 55].
4.9 ex and Gender Differences

S asthma, one in four will show improvement dur-
in Asthma ing pregnancy.
There are many unknowns in terms of sex
While sex and gender are often considered differences in asthma. For example, studies of
together, these two words have different mean- variations in bronchial hyperreactivity by sex
ings. Sex is about biological differences, but gen- show no consistent pattern. It is not clear if
der is about differences in social interactions. some medications might be more effective in
These differences will matter in this section, but woman rather than in men and vice versa. Given
it should be stated at the outset that there is very the recognized differences in the adult lung, an
little information available on gender differences organ that is smaller and with fewer alveoli in
in asthma, but there are numerous studies on sex females, it is surprising that detailed studies of
differences. Hence, the focus of this section will drug deposition by sex have not been done.
be on sex differences. Some differences in male/female differences in
Some sex differences relevant to asthma adults with asthma may be related to different
become apparent at birth and may also be present patterns of occupation and hence different pat-
in fetal life. Some of these may not lead to any terns of allergen and irritant exposure. Having
changes in how we investigate or manage asthma, said that, given the rapid societal changes occur-
and others are not well understood. For example, ring today, this may be something of historic,
the lungs of girls are more differentiated at birth, but not current, interest.
but the lungs are smaller and with fewer bronchi- There are clearly practical implications for the
oles. Having said that, the incidence of asthma is educator in obtaining a history and in planning a
much greater in males in the preschool years than treatment regimen with both men and women.
in females. This differential continues until One issue that is often overlooked is that of peri-
puberty. During and after puberty, asthma is more menstrual asthma. Questions about menstruation
likely to develop in women as compared to men, and its relationship to asthma are always required,
and when it does occur, it is likely to be more and a supplementary question would be about
severe. For example, admissions are more fre- any effect of oral contraceptives. Some studies
quent in women aged between 20 and 50 years have shown a reduction in perimenstrual asthma
than in men of the same age. This continues until with oral contraceptives. Traditionally, oral con-
the menopause, and use of hormone replacement traceptives include a hormone-free interval. This
therapy may prolong this difference for several was an essential feature at the time contracep-
years [56]. tives were started, as delayed appearance of men-
Sex differences currently known to exist will struation was the commonest early sign of
have many contributing factors, but it is difficult pregnancy. These days pregnancy can be diag-
to ignore the possibility that many of these differ- nosed easily by over-the-counter tests, and hence
ences are related to hormonal influences. For that hormone-free interval is no longer necessary.
example, in the previous paragraph, there was an Suggestions have been made to reduce it from 7
allusion to the greater likelihood of asthma devel- to 2 days.
oping after puberty in females and that this ten- At a higher, macro level, epidemiological
dency is much more marked when menarche is and intervention studies of asthma should ana-
early. In adult woman, perimenstrual asthma is a lyze data from men and women separately. Such
distressing phenomenon [57]. Asthma presenta- data will be very helpful to prescribers. The
tions to emergency departments are much com- pharmacology and pharmacokinetics of the var-
moner in the first day or so of menstruation than ious medications used in asthma again must be
at other times in the cycle. Asthma during preg- studied in detail in men and women separately.
nancy may become worse in one out of three One overarching unknown requiring research is
pregnancies, but deterioration is not invariable. It the lack of information on differences in asthma
should also be noted that among women with by gender.
4.10 Avoiding Delays in Diagnosis 125
4.10 Avoiding Delays in Diagnosis routinely order spirometry for those with dys-
pnea or cough. Despite the limitations of spirom-
Asthma presents a continuum that ranges from a etry, it remains an essential investigative tool for
mildly intermittent problem to a life-threatening those with dyspnea, wheeze, or cough.
situation and death. Those at the mild end may All this having been said, though, the ques-
have symptoms only with colds or extreme exertion remains: Does it really matter? The evidence
cise and are unlikely to regard themselves as hav- is not at all clear about the benefits of early diag-
ing a “disease.” Delay in diagnosis or even nosis. Does it make a difference to the persis-
non-diagnosis in this group is understandable, tence of the disease or the physical changes of
and a diagnosis of asthma, when finally made, airway remodeling? In one sense, it does not; in
may make little difference in their lives. The evi- another sense, early diagnosis is very important.
dence suggests that many persons who exhibit The sooner the diagnosis is made and effective
definite evidence of asthma, yet fall far short of treatment started, the sooner the reduction in
being in a life-threatening condition, may go for human suffering from asthma, improvement in
years before being diagnosed. Given the empha- the quality of life, and prevention of airway
sis on asthma in the medical literature and in all remodeling.
forms of media directed at the public, this is What must healthcare professionals and edu-
surprising. cators do in order to encourage early diagnosis?
The studies do not give a clear explanation One obvious answer is more effective public
for this delay in diagnosis. Because the condi- education and awareness through the media.
tion is not “clear-cut,” it is speculated that one Public awareness is as important as healthcare
factor may be the lack of a simple and widely provider awareness. In some areas, an alliance of
accepted definition of asthma. Second is the Lung Associations and professionals has used
lack of a definitive test. The various pulmonary shopping malls and other public venues to
function tests have their limitations and were inform the public. At these locations, simple
described in Chap. 3. Airflow obstruction and its symptom questionnaires were combined with
reversibility with a bronchodilator are an impor- spirometry to assess the likelihood of asthma.
tant feature of asthma, but can also occur with However, the persons tentatively identified in
other diseases. Similarly, airway reactivity, this manner still needed to be assessed by knowl-
while an essential feature of asthma, is not edgeable healthcare providers in order for a defi-
exclusive to asthma. nite diagnosis to be made and to have access to
Symptoms are very important in the diagnosis skilled educators who would provide appropriate
of asthma, and there is no single symptom that follow-up.
will conclusively confirm that asthma, rather than The symptoms of asthma can be confused
some other illness or condition, is present. Even with those of many other diseases. There are
the cardinal symptoms of cough and wheeze can some pitfalls, therefore, in focusing public edu-
be caused by other diseases, thereby requiring the cation on asthma rather than on respiratory dis-
healthcare provider to carefully assess their sig- ease in general. In particular there is a real risk of
nificance. Individuals with asthma will often confusing dysfunctional breathing with asthma.
deny symptoms to some extent and may wait a That complex includes abnormal breathing pat-
long time before they seek specific advice from terns that cause breathlessness, chest tightness,
their healthcare provider. chest pain, light-headedness, paresthesia (abnor-
Physicians and healthcare providers may also mal sensation), and anxiety. In a study [58] of
delay in making the diagnosis. The danger of individuals with asthma who attended a family
abusing the phrase “reactive airways disease” has practice, it was found that between one-third and
already been discussed. A healthcare provider one-fifth of those diagnosed with asthma had evi-
may not think of asthma when wheeze is absent. dence of dysfunctional breathing, instead of or in
In addition, many healthcare providers do not addition to the asthma.
This does not imply that identification of • Be able to make decisions that help to control
asthma should be done later. There is a need for or manage their asthma
case findings to be followed by precise diagnosis, • Know when to seek medical help, based on
objective confirmatory testing, and careful fol- symptoms and peak flow readings.
low-up. The educator has a particular role in fol-
low-up to identify those who may turn out not to Monitoring should include an assessment of
have asthma and to help identify those who turn the impact of the asthma on their quality of life.
out to have disorders such as anxiety or panic dis- Some of the items mentioned earlier, such as time
orders in addition to asthma. lost from work or school, the frequency of sleep
disturbance, and exercise intolerance, can be
recorded in diaries. A simple rating system—
4.11 Monitoring Asthma using words such as “no effect” or “minimal
effect” or “major effect”—can be used to docu-
Asthma is a chronic condition, and those who ment the severity. Alternatively, a scale of 1–10
have it should know how to monitor it and how to could be used, with “1” indicating no effect and
assess its severity. They must do this daily and “10” indicating a major effect.
must have the necessary knowledge and informa- The use of bronchodilating medications is
tion to do so correctly. Without these two ele- very important in monitoring asthma. They
ments, the chances are unlikely that reasonable relieve both symptoms by reversing bronchocon-
and responsible decisions will be made. striction. However, better approaches to long-
If there is a lack of information, the person term treatment than regular bronchodilator
with asthma will frequently visit and seek advice therapy exist, and current practice calls for bron-
from a healthcare professional, including a health- chodilating medications to be used only as
care provider. In other words, it is ineffective and needed. The frequency of beta-agonist use should
a waste of healthcare resources for persons with a always be recorded in a daily diary, and the
chronic illness to seek medical advice for every healthcare provider should inquire about this or
symptom. The healthcare professional has the check it at every clinic visit.
responsibility of making a timely diagnosis. If the Very detailed questions must be asked during
diagnosis is followed by education and the correct the clinic visit. For example, many users may
treatment, then self-management with occasional, have access to more than one beta-agonist or
appropriate professional help will occur. more than one delivery system and may not
This rule applies equally to everyone with fully understand that the various medications
asthma—each individual must know enough to are not really different but are part of one class
be in charge of their own treatment, and to of medication. Some will not fully understand
make the decisions that can control and mini- the difference in dose between medication given
mize the impact of asthma on their lives. They by nebulizer and that given by metered dose
must also understand the limitations of this inhaler. (With albuterol, a standard dose by neb-
approach and know when they must consult a ulizer provides ten times the dosage of a stan-
professional to help them in dealing with it. dard puff from a metered dose inhaler (MDI).
They should: However, given that nebulizers are an inefficient
delivery system that dispense a wide range of
• Know their triggers and how to avoid them particle sizes, many of which impact in the oral
• Know their symptoms and pattern of asthma cavity, the lower dose might sometimes be more
• Be able to use peak flow meters to detect effective.) Hence careful questioning is required
changes against their normal baseline both to elicit the necessary information and to
• Know how to interpret the peak flowchart instill awareness that overuse of bronchodilators
• Be able to apply their action plan based on indicates asthma that is out of control. See
their peak flow readings Fig. 4.12.
4.12 Referral to a Specialist 127
correspond to improvement in asthma control

after ICS treatment [59, 60]. Higher levels are
associated with more exacerbations and with a
decline in lung function [61]. When used with
other monitoring methods [62], FeNO is useful
in predicting exacerbations after reduction or
withdrawal of ICS and results in a significant
reduction in exacerbations of varying severity
[59, 63]. The most recent recommendations [62]
preach caution in widespread use of FeNO
before further evidence is available. In particu-
lar, treatment should not be decreased based on
FeNO alone.
Fig. 4.12 Peak flowchart showing deterioration and fluc-
tuations caused by increased usage of a bronchodilator. (©
The Asthma Education Clinic Ltd) 4.12 Referral to a Specialist
The information in this book is intended to help

4.11.1 Fraction of Exhaled Nitric the educator care for individuals with asthma.
Oxide (FeNO) Educators may be healthcare professionals who
work alone, or work as part of a team, or be quali-
FeNO can also be used to monitor an individual’s fied healthcare providers. The professions
asthma. In a manner similar to that used for peak involved in asthma education include nurse prac-
flows, an individual’s personal best FeNO read- titioners, physicians, respiratory technologists,
ing is taken in order to establish a baseline with nurses, and pharmacists, to name a few. All of
subsequent readings taken at each clinic visit or these complementary, supportive elements will
after a corticosteroid burst. Since FeNO corre- affect whether or not an educator may need to
lates to eosinophilic inflammation, it is a guide to refer an individual to someone else at some time.
therapy. In addition they may have been assessed by a
The American Thoracic Society suggests that variety of primary care practitioners including
a significant response to therapy is indicated nurse practitioners, family physicians, general
when, from one visit to the next, there is internists, pediatricians, or an osteopath. These
primary care practitioners may work with the
• 20% or greater decrease for values over 50 ppb educator, or there may simply be a collegial rela-
• More than 10 ppb drop for values lower than tionship within which individuals with asthma
50 ppb are referred to one or another.
The core team—primary healthcare provider
High levels of FeNO are found in untreated or and educator—will be able to successfully man-
symptomatic asthma. FeNO has been found to age most individuals with asthma. However,
rise some cases will need additional expertise, and
this is when other specialists must join the team.
• When anti-inflammatory therapy is stopped These may include an allergist and/or a pulmon-
• After an allergen challenge ologist, either pediatric or adult, as the case may
• After a viral infection be. A few will need referral to an otolaryngolo-
• Prior to an exacerbation gist (ear, nose, and throat surgeon), a gastroenter-
ologist, and perhaps some other specialist. The
Since high levels of FeNO correlate with main reason for referrals to one of these special-
eosinophilic inflammation, FeNO levels also ists would include [6, 64]:
• Severe asthma, either a life-threatening exac- 2. Wenzel SE, Larsen GL. Assessment of lung func-
tion: pulmonary function testing. In: Bierman CW,
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Environmental Issues in Asthma
Management
5
Contents
5.2 Environmental Issues and Common Triggers of Asthma 133
5.2.1 Outdoor Allergens 133
5.2.1.1 Pollen 133
5.2.1.2 Molds 134
5.2.2 Indoor Allergens 135
5.2.2.1 Dust Mites 135
5.2.2.2 Cockroaches 135
5.2.2.3 Rodents 136
5.2.2.4 Pets 136
5.2.2.5 Mold 137
5.2.2.6 Ladybugs 137
5.2.2.7 Latex 138
5.2.2.8 Cannabis 138
5.2.3 Irritants 139
5.2.3.1 Air Pollution 139
5.2.3.2 Tobacco 139
5.2.3.3 Other Irritants 140
5.3 Ingested Allergens 140
5.3.1 Oral Allergy Syndrome 142
5.3.2 Food Additives 142
5.3.2.1 Sulfites 143
5.4 Non-allergenic Triggers or Irritants 143
5.4.1 Cold Air 143
5.4.2 Exercise 144
5.4.3 Emotion 144
5.4.4 Viral Infections 144
5.4.5 Medication Sensitivity 144
5.5 Exposure Reduction and Avoidance Techniques 146
5.5.1 Pollen 146
5.5.2 Mold 148
5.5.2.1 Outdoor Mold 148
5.5.3 Dust and Dust Mites 149
5.5.4 Cockroach Allergen 151
5.5.5 Pet Allergen 151
5.5.6 Rodent Allergen 153
5.5.7 Food Allergen 153
132 5 Environmental Issues in Asthma Management
5.5.8 Medications 154

5.5.9 Insect Allergen 154
5.5.10 Irritants 155
5.5.11 Viral Infections 156
5.5.12 Cold Air 156
5.5.13 Exercise 157
5.5.13.1 Asthma and the Athlete 158
5.5.14 Latex 158
5.5.15 Conclusion 158
5.6 Identification of Triggers 159
5.7 Home Assessment 159
5.7.1 Smoking 161
5.7.2 Vaping 162
5.8 Application 163
References 164
Key Points 5.1 Introduction
• Environmental allergens are common Self-management of asthma is a key consider-

triggers of asthma. ation and should always be encouraged. If a per-
• Allergens might be outdoor, indoor, son with asthma is to self-manage successfully,
or ingested. however, certain conditions must be met, and cer-
• Irritants can be non-allergenic triggers tain skills are essential. He or she must:
or irritants.
• Smoking and vaping are also impor- • Be well-educated about the disease.
tant triggers. • Be able to recognize when the medication is
• Identification of triggers is important. not working and how to change the treatment.
• Home assessment is often helpful. • Know when to seek professional advice.
• Triggers of all types can be dealt with by • Be able to identify environmental factors
exposure reduction and avoidance which may lead to deterioration in asthma.
techniques. • Use medications correctly, both to prevent
symptoms and to treat them.
Many recent advances in drug therapy have

led to the incorrect belief that environmental
Chapter Objectives issues are not important and that asthma manage-
After reading this chapter, you should be ment is “simple.” It is believed that the prescrip-
able to: tion of an effective drug and an effective device
will by themselves lead to success. This is only
1. List the different triggers of asthma and partly true. A much more comprehensive
explain how to avoid them. approach is required to achieve sound asthma
2. Discuss the effects of smoking, particu- management that improves the quality of life.
larly on infants and children with The major goal of asthma management is to
asthma. allow a “normal” or “near-normal” life for every-
one with asthma. This implies:
• The ability to exercise without symptoms. 5.2 Environmental Issues

• Symptoms that are infrequent or completely and Common Triggers
absent. of Asthma
• Symptomatic treatment that is rarely or never
needed. Most studies support the importance of both
• No exacerbations or only exacerbations that allergen avoidance and environmental control in
are easily controlled. the management of asthma [2]. A reduction in
• No unexpected and urgent visits to healthcare allergen exposure will reduce BHR [3–5] and
providers. symptoms and increase PEF [6–9]. It should be
• No ED visits and hospitalizations. noted, though, that certain studies have generated
contradictory results [10].
Children with asthma should be able to sleep, The following are the main environmental-
learn, and play with their peers. In order to suc- related items that must be considered by all per-
cessfully achieve what is known as “patient sons with asthma:
adherence,” these goals must be achieved with a
minimum of medications, dosages, and side 1. Outdoor allergens.
effects. • Pollens.
There are obvious limits to a “normal” life- • Molds.
style. For example, individuals with asthma 2. Indoor allergens.
must avoid specific environments and should • House dust mites.
not keep pets in the house. Proper environ- • Cockroaches.
mental management is extremely important, • Rodents.
and high-dose drug therapy should never be • Animal emanations.
used in order to permit exposure to known irri- • Molds.
tants or allergens. Immunotherapy should be • Ladybugs.
considered for all persons with a major aller- • Latex.
gic component to their asthma or who have • Cannabis.
problems with allergies distinct from the 3. Irritants.
asthma [1]. Specific considerations are dis- • Air pollution.
cussed in Chap. 8. • Tobacco, cigarette smoke, and vaping
This chapter has three sections. devices.
• Wood smoke.
• Situations in which possible triggers of asthma • Chemical odors.
are identified.
• Exposure/reduction techniques which Each of these is now discussed in some detail.
explain how persons with asthma can be
shown how to avoid or reduce exposure to
triggers. 5.2.1 Outdoor Allergens
• Identification of triggers. Knowing that trig-
gers exist is not enough. The healthcare pro- 5.2.1.1 Pollen
vider and the individual should be able to Asthma triggered by pollen is extremely com-
identify environmental triggers in the home or mon. Pollen from trees, grasses, and weeds that
workplace. Methods and techniques for trig- are wind pollinated are the most common trig-
ger identification are described. gers [11]. These include:
• Tree pollen of alder, ash, birch, cedar, elm,

hazel, juniper, maple, and oak. Points to Ponder
• Pollen from Kentucky blue, Bermuda, Goals of asthma management.
Johnson, orchard, ryegrass, and timothy • Maintain normal activity levels.
grasses. • Prevent exacerbations.
• Weed pollen from amaranth, dock, nettle, • Prevent symptoms.
plantain, lambs’ quarters, mugwort, pigweed, • Use the least amount of medication
thistle, Russian thistle, ragweed (tall and necessary to achieve control.
short), sagebrush, and sheep sorrel. • Minimize side effects of medication.
• Maintain normal pulmonary
The time and duration of the pollen season are function.
dependent on elevation and geographic location.
Furthermore, in those areas which have four dis-
tinct seasons, specific pollens are associated with
each. For instance, trees pollinate from late win- When the pollen count is high, sensitive indi-
ter through early spring, grasses from late spring viduals should probably remain indoors, particu-
through early summer, and weeds from early larly at midday and in the afternoon. If windows
spring through autumn. Pollen concentrations are are open, which is common in the summer, there
higher at the beginning of each season than at the may be little difference between the concentra-
end. tion of pollen outdoor and of that indoors.
Many factors affect the timing of pollen
release and dispersal [9, 12]. Atmospheric condi- 5.2.1.2 Molds
tions are one such factor, and they include tem- Molds are fungi with very light spores that easily
perature, humidity, wind speed, turbulence, and float in the air. Outdoor molds are present in dif-
changes in climate [13, 14]. Pollen is airborne ferent regions at different times and may grow on
when weather conditions are hot and dry, but not grains, grass, dead leaves, and other media. The
found in the atmosphere on rainy days. Wind aids most common types of outdoor mold spores are
dispersal. Alternaria, Cladosporium, and Aspergillus [21].
Pollen allergens are present as small respira- Alternaria and Cladosporium have been linked to
ble particles in the air. Large particles of pollen epidemics of asthma and to life-threatening
(greater than 10 microns in diameter) usually do asthma exacerbations [22]. Other molds (e.g.,
not penetrate to the lower airway. Particles asso- Mucor, Rhizopus, Penicillium, and some other
ciated with ragweed and with grass pollen of less forms of the fungi Aspergillus) grow indoors on
than 10 microns diameter are common triggers. foods and leathers and in basements. Fungi are a
Epidemics of asthma have been linked with source of allergens and can trigger asthma exac-
thunderstorms [15–19] followed by heavy rain- erbations [23].
fall. Together these fracture and release signifi- The concentration of fungal spores in the air is
cant amounts of micron-sized particles from related to and dependent upon the rainfall, humid-
grass pollen. One theory suggests that pollen ity, temperature, winds, seasonal climatological
grains normally too large to enter the airways are factors, and the patterns of light and darkness.
shattered into smaller particles that can do so and Cladosporium and Alternaria are wind-blown
that subsequently provoke a response [11, spores whose airborne quantities increase with
17–20]. airflow and reduced humidity. Thus, they are
Symptoms will appear at different times in abundant at midday, during periods of maximal
different individuals. The health professional can sunlight [11].
obtain clues by requesting a careful history of Asthma exacerbations have been linked with
symptoms, particularly nasal symptoms at a par- high outdoor spore counts which result in sea-
ticular time of year. sonal asthma “epidemics” that require hospital
visits [24]. This has been observed during the In order to survive, house dust mites (HDM)
months of September to November in New require high humidity, moderate temperatures,
Orleans, USA [25]. The presence of and a plentiful food source, which they obtain
Cladosporium, Alternaria, Aspergillus, and from sloughed-off human skin (skin scales).
Penicillium species in particular increases the HDM are found in upholstered furniture, carpet-
risk of asthma symptoms and exacerbations [26]. ing, bedclothes, mattresses, pillows, stuffed toys,
Aspergillus may cause two discrete syndromes, and pet areas. They thrive at an indoor relative
in addition to increasing asthma symptoms: inva- humidity of 60% at 21 °C or 75% at 16 °C [10].
sive aspergillosis and allergic bronchopulmonary The allergen that triggers asthma is found both in
aspergillosis (ABPA). Those sensitive to outside dust mite bodies and in their fecal pellets. Early
molds should stay indoors, with their windows childhood exposure to dust mite allergen has
closed, during seasons of high mold production, been linked with the development of persistent
and especially on windy days. asthma, acute exacerbations, and reduced lung
function in children [33–35].
Increased altitude and lowered humidity will
5.2.2 Indoor Allergens reduce the number of dust mites. They cannot
survive when the relative humidity is less than
Indoor allergens are strongly associated with 50%. Thus, one way to eliminate them is to
allergic asthma [27] and have been linked to the ensure that relative humidity stays below this
increase in perennial rather than seasonal asthma. level. Dust mite levels are highest in summer and
A positive correlation has been found between early fall, when humidity and temperature are
sensitization to specific allergens and the mean high, and lowest in winter when both temperature
level of allergen found in the home [28]. and humidity drop. HDM require a minimum
temperature of 25 °C to breed [36, 37].
5.2.2.1 Dust Mites
House dust is largely comprised of fibers result- 5.2.2.2 Cockroaches
ing from the breakdown of plant and animal Cockroach feces are particularly prevalent and
material in the home, such as cotton, wool, responsible for asthma exacerbations in inner cit-
hemp, jute, feathers, and animal hair. It hence ies and rural small towns in the USA.
contains major indoor allergens. The allergic Cockroach allergen is a significant risk factor
component of dust includes animal dander and for asthma among inner-city residents [38, 39];
saliva, dust mites, mold, and cockroach feces. it is also associated with lower pulmonary func-
Exposure to low levels of mite allergen has been tion in children with asthma [40]. Cockroach
found to be a significant risk factor for sensitiza- levels in homes are a risk factor for reduced
tion [29, 30]. FEV1 independent of airway responsiveness
Exposure to dust mites occurs within the [41]. In a study in New York City of 45 indi-
home, and until recently it was believed, without viduals with asthma, aged over 60 years, cock-
question, that the greatest exposure occurred in roach allergen was the most common allergen to
bed at night [30]. It turns out the convenient which subjects were sensitive (47%) [42].
assumption was inaccurate. For example, expo- Roach allergen is found in the whole body of the
sure also occurs outside the home with the high- cockroach and in its saliva, secretions, feces,
est exposure on public transport. By contrast, the egg casings, and cast skin fractions. It can also
lowest exposures are overnight in bed. In terms of be found in their regurgitated digestive juices—
exposure in the home, the greatest exposure is in a brownish stain that is often mistaken for cook-
activities around the home when next to other ing grease. High levels of cockroach allergen
people. Daycare centers, schools, and occupa- have been associated with food debris, cock-
tional settings too may provide high levels of roach activity, and the presence of a tobacco
exposure [6, 31, 32]. smoker in the home [43].
5.2.2.3 Rodents 5.2.2.4 Pets

Rodents include mice, rats, hamsters, gerbils, and Any warm-blooded pet, including small rodents
guinea pigs. Rats are a public health problem. (hamsters) and birds, may cause an allergic reac-
Exposure to rat allergen can result in increased tion. Any pet can exude proteins in excretions,
hospitalizations, unscheduled medical visits, and secretions, and dander. Sensitization to cat and
reduced activity levels in children with asthma dog allergen is associated with asthma [50].
[44]. Rodent allergens are associated with Among individuals with asthma, between 40 and
increased asthma morbidity, particularly among 70% show positive skin test reactions to cat and/
urban, low-income children [45]. The concern or dog dander. Other animals kept as pets—such
over exposure to rats and mice (which is dis- as mice, rats, birds, iguanas, guinea pigs, rabbits,
cussed next) is the obvious strong correlation cows, and horses—also cause allergic reactions,
with low socioeconomic status. In turn, this but cats are the most prevalent cause of pet
implies an association with social determinants allergy. Pets are also reservoirs and carriers of
of health. dust mites [51].
Inner-city schools and daycare locations All breeds of cat produce allergens, and cat
have been found to be reservoirs of mouse aller- saliva and cat dander contain very powerful aller-
gen [32, 46, 47]. Bedrooms are an important gens. The cat’s pelt, saliva, urine, lachrymal fluid,
source of both rat and mice allergens. The as well as excretions from sebaceous and anal
mouse allergen Mus m 1 is secreted in mouse glands are sources of allergen. Known as Fel d 1,
urine, and since it is <10 microns, it remains with a particle size of less than 2.5 microns in
airborne for long periods of time. It has been diameter, cat allergen is readily airborne and
found in the bedrooms of over 80% of homes in remains so for long periods of time if a room is
the USA, while 30% of homes had the rat aller- left undisturbed [52]. It can be found on furni-
gen Rat n 1 [42]. While kitchen floors and bed- ture, upholstery, carpets, walls, curtains, floors,
room floors contained mouse allergen, it was mattresses, and clothing. As it is sticky, it is car-
also found in bedroom air. An urban study ried on clothing and hair [53] and is so widely
found that there was a dose-response relation- distributed that it is found in areas where cats are
ship between concentrations of bed mouse not normally found, such as medical offices,
allergens and increased use of asthma-related newly built homes, schools, daycare locations,
healthcare in that for every tenfold increase in workplaces, grocery stores, cinemas, public
mouse allergen, there was a corresponding 87% transportation, cars, shopping malls, and hospi-
increase in the utilization of asthma healthcare tals [54, 55]. Cat allergen has even been found in
services such as ED visits or unscheduled pro- homes where there are no cats. In 1 detailed study
vider visits [48]. of 405 randomly selected homes, dust was col-
In a study involving inner-city children with lected and analyzed for the presence of Fel d 1. It
asthma in Boston and Baltimore, sensitization to was found to be present in 99% of homes with a
mouse allergen was an independent risk factor cat, 55% of homes that had a cat in the last year,
for rhinitis [49]. and 28% of homes without a cat [56]. In schools,
Risk factors for detectable airborne mouse cat allergen levels can trigger an asthma exacer-
allergen in homes include exposed food remains, bation in students who are already sensitized—
holes or cracks in doors or walls, and evidence of even though these students may not have a cat at
mouse infestation such as droppings, signs of home.
fresh gnawing, and tracks. Poor sanitation attracts Dog allergen, Can f 1, is not as ubiquitous as
mice and rats. Mice can survive in very small cat allergen but can still trigger asthma attacks.
areas with limited amounts of food and shelter. Sensitive individuals with asthma who are
As noted, all these factors can be summarized as exposed to high levels of cat or dog allergen in
social determinants of health. their bedrooms will have significantly more
asthma attacks and greater asthma morbidity than and mold is associated with asthma exacerba-
nonatopic individuals with asthma [43, 57]. tions at all ages [65, 66].
There is no such beast as a “non-allergenic” Mold in the workplace is associated with the
dog. Short-haired dogs are as allergenic as those development of asthma in adults [67]. Indoor
with longer hair. The data suggests that a hypoal- mold growth can be limited by avoiding excess
lergenic cat or dog might be a profit center for humidity [13], by ensuring good ventilation, and
the supplier, but these animals do not produce through proper maintenance of household appli-
less allergen in their saliva, fur/hair, or urine. ances, such as heaters and humidifiers.
One particular study showed that a so-called
“hypoallergenic” dog had higher allergen levels 5.2.2.6 Ladybugs
in its hair and coat than non-hypoallergenic dog The Asian ladybug (ALB) is a new seasonal aller-
breeds [58]. gen and now increasingly seen in the USA. While
Techniques for dealing with animal dander, it is more common in rural and suburban areas,
house dust mites, and cockroaches, including ALB can also be found in cities. Imported by the
avoidance and minimization of contact with these US Agricultural Department to provide natural
allergens, should be discussed with all those who ecological control of aphids, they are now con-
have asthma. (See Sect. 5.5) sidered a pest, replacing the native ladybug. ALB
are generally an outdoor insect, but as winter
5.2.2.5 Mold approaches, they search for warmth and enter
Mildew is caused by molds. Indoor molds may light-colored houses through cracks and crevices
occur in stuffed animals, furniture, mattresses, where they swarm in hundreds and thousands to
and humidifiers, and may cause year-round spend the winter in a state of near hibernation
symptoms [59]. In the European Community [68]. In spring, they head back outdoors leaving
Respiratory Health Survey, indoor mold was many dead. Thus, they are a seasonal allergen
shown to have an adverse effect on adults with with symptoms increasing in spring, fall, and
asthma [60]. In a Canadian study, high levels of winter and easing though late spring and summer
mold were found to be a risk factor for asthma in [69–71].
children [61]. Exposure to mold in the classroom The allergens of the ALB are Har a 1 and Har
was significantly associated with asthma symp- a 2 and are in the body parts and the yellow,
toms that improved when students were away stinky fluid (reflex bleeding) they secrete when
from school for weekends or holidays [62]. In handled, frightened, or squashed. Individuals can
adults, a specific mold, Trichoderma citrino- be exposed to the allergen not only at home but
viride, a widespread soil fungus, was associated also at work, school, and other settings [72].
with the development of asthma [63]. Reactions can be due to inhalation resulting in
Molds grow best in warm, moist environ- asthma, chronic cough, rhinitis, urticaria, and
ments. Damp areas (bathrooms and laundry angioedema [70]. Localized reactions result from
rooms) are particularly prone to breeding bites. Individuals who are sensitive to cockroach
grounds. Major sources of mold are to be found allergen tend to react to ALB [71].
in food storage areas, bathrooms, shower cur- Treatment of this allergy involves avoidance.
tains, carpeting, humidifiers (especially the All cracks and crevices around doors and win-
humidifier drum), plant soil, garbage containers, dows and in exterior walls should be carefully
window sills, rotting floors, wallpaper that has sealed. Prior to the start of cold weather, the out-
been damaged by water, basements, and damp side of the house should be treated with pyre-
firewood. Mold is also found in food containers throids. Painting the exterior of the house a darker
and upholstery. color does not help [71].
Infants exposed to moisture damage and mold Once ALB are inside a house, it is difficult to
in their living areas are at high risk of developing get rid of them. Regular cleaning and vacuuming
asthma [64]. Exposure to indoor fungal spores with a crevice tool will help reduce the allergen
load. If the house is infested, professional help to pineapples, etc. About 50% of individuals with an
exterminate them should be sought. allergy to latex have concomitant food allergies
[79]. See Oral Allergy Syndrome in Sect. 5.3.1.
5.2.2.7 Latex The reaction to latex allergy can include wors-
Latex allergen is worth noting because it is of ening eczema; asthma; oral or facial swelling;
growing concern and because latex products are gastrointestinal disorders; itching of the eyes,
in widespread use. Latex can affect health profes- ears, and throat; rhinitis; sinusitis; and even ana-
sionals [73]: those who have repeated surgeries; phylaxis (the term used to describe a life-threat-
workers in the food, computer assembly, toy, and ening allergic reaction) [79, 80].
tire manufacturing industries; and all those whose
work requires contact with latex in the form of 5.2.2.8 Cannabis
rubber products, adhesives, or gloves. It is recog- Marijuana or cannabis is the second most widely
nized as an inducing agent for occupational smoked substance and the most commonly used
asthma [74]. psychotropic drug in the USA. Nearly 4% of
The reaction to latex is IgE mediated due to grade 12 students use marijuana daily, and the
proteins in natural rubber or those chemicals rates of use among students has risen as teens’
used during manufacture. The latex protein easily perception of its risks has decreased [81, 82].
binds to the cornstarch used to coat the inside of Among the general population, it is used both
rubber gloves and becomes an aeroallergen that recreationally and medically.
is easily inhaled [75]. Repeated exposure through Allergy to Cannabis sativa is increasing, par-
contact (cutaneous, mucosal, or parenteral) or ticularly due to recent legislation that permits
through aerosol transmission and inhalation has the sale of cannabis in many forms. Exposure to
been known to result in anaphylaxis, a severe, cannabis can occur through ingestion, inhala-
life-threatening allergic reaction. Systemic reaction (including second-hand exposure), and
tions with mucosal and parenteral exposure are cutaneous and aeroallergen contact [83].
linked to the greatest risk of anaphylaxis Ingestion of foods containing cannabis, canna-
[76–78]. bis tea, oil, or hemp seeds can result in symp-
Latex is found in or on many medical prod- toms. Marijuana smoke contains carcinogens
ucts: tubes, cannulas, catheters, vials, IV ports, that with heavy use may lead to chronic bron-
dental dams, blood pressure cuffs, face mask chitis and cancer [81, 82].
straps, bandages, stethoscope tubing, syringe The cannabis allergen, Can s 3, causes symp-
stoppers, electrode pads, tourniquets, wound toms from both direct and indirect exposure.
drains, anesthesia circuitry, and injection ports. Symptoms associated with cannabis use include
Latex is also found in non-medical products lacrimation, rhinitis, rhinoconjunctivitis, nasal
such as balloons, rubber gloves, condoms, shoes congestion, sore throat, cough, dyspnea, wheez-
and boots, elastic used in underwear, belts, esca- ing, pharyngitis, pruritus, contact urticaria, and
lator handrails, shoe soles, sports equipment, dia- angioedema. Reactions range from mild to
phragms, dishwashing gloves, hot water bottles, severe, from allergic reactions to anaphylaxis. It
rubber bands, erasers, goggles, masks, bicycle is a trigger for asthma symptoms and exacerba-
and motorcycle grips, adhesives, and foam and tions. It is known to reduce vital capacity and
carpet underlay—to name but a few. Another trigger bronchitis in chronic users. The intensity
source of exposure is the flakes of rubber from of reactions depends on the route of exposure
radial tires to be found in air near busy highways. [83–86].
The only latex item that does not contain latex is A study of second-hand exposure in an unven-
latex paint [77]. tilated area found that it can result in absorption
Anyone with an allergy to latex should be of cannabinoids with traces found in blood and
made aware of the possibility of cross-reactivity urine. It also affects psychomotor ability and
with certain fruits such as avocados, bananas, memory, producing non-lasting behavioral and
cognitive effects [87]. Another study found that from newspapers, radio, television, and a number
prenatal exposure to cannabis doubles the risk for of websites such as AAAAI.org and IQAIR.com.
autism spectrum disorder [88]. The latter displays air quality and PM2.5 air pol-
Cannabis can be a health hazard for workers lution indices for “anywhere in the world.”
who handle and process the cannabis plant and be High exposure to air pollutants in the week
a source for occupational exposure [83, 89, 90]. before a viral infection increases asthma symp-
Sensitization to cannabis allergens can result in toms by 200%, increases the severity of the exac-
allergy to other plant foods. Known as cannabis- erbation, and reduces lung function [107].
fruit/vegetable syndrome, sensitization may cross- Indoor air pollutants are often similar to out-
react with cherry, hazelnut, peach, tangerine, door air pollutants. Outside air, with its pollut-
tobacco, latex, and plant food-derived alcoholic ants, herbicides, pesticides, and lawn treatments,
beverages [83, 91]. The danger lies in the fact that will intrude indoors. Construction materials from
this syndrome may result in anaphylaxis to fruit new homes or from renovations will leech pollut-
that was previously tolerated. It has a significant ants into indoor air. New carpets will release
impact on the individual’s quality of life [92]. gases (a process known as off-gassing) at high
The only solution to cannabis allergy and to levels for the first 2 months after which the level
cannabis-fruit/vegetable syndrome is avoidance. will slowly decrease over 2 years. Environmental
pollution affects respiratory function and disease
more than heredity [108].
5.2.3 Irritants
5.2.3.2 Tobacco
5.2.3.1 Air Pollution Tobacco smoke, in particular, is not an allergen
Asthma exacerbations are increased by irritants but an irritant. It does not trigger an allergic
such as air pollution (particularly sulfur dioxide) response, but it has major harmful effects on
[93–96], dust, and tobacco smoke. While air pol- those exposed to it [109–112], particularly chil-
lution has not been shown to cause asthma, it dren with asthma. Any environment contami-
clearly may cause exacerbations of pre-existing nated in any way with tobacco smoke is entirely
asthma [97]. Outdoor air pollutants include unsuited for any person with asthma. This is a
ozone, carbon monoxide, sulfur dioxide, nitric very difficult issue to deal with, as it involves a
oxide, volatile hydrocarbons, and black smoke. potent addiction. If a smoker lives in the same
Ambient air pollution has been linked to an house as someone with asthma, a high degree of
increase in hospital admissions and emergency support is needed for both individuals. Smoking
room visits. Children with asthma in Japan were cessation measures are obviously indicated, but
shown to be much more likely to visit the emer- may not be acceptable. At the very least, the edu-
gency room on misty and foggy nights than on cator should develop strategies to reduce the
clear nights [98]. exposure to tobacco smoke as far as the person
Exposure to air pollutants results in a drop in with asthma is concerned. Socioeconomic prob-
FEV1, FVC, and PEF and increased BHR [99– lems are a related factor: when compared against
104]. A study on high exposure to pollutants in households with pets, households with smokers
the week before a viral infection showed their have poorer resources and more stress [113].
effect on persons with asthma with the result that Smoking damages the cilia in the lungs and is
asthma symptoms increased by 200%; and there a known carcinogen. Second-hand smoke or
were both increased severity of exacerbation and environmental tobacco smoke (ETS) has also
a greater decrease in lung function [105]. been classified by the US Environmental
Exposure to outside air pollutants, particularly Protection Agency as a Group A carcinogen
ozone and sulfur dioxide, increases asthma symp- [114]. Third-hand smoke—the traces of smoke
toms and asthma exacerbations [106]. Information left on the hair, skin, and clothing of a smoker—
on outdoor air pollution can usually be obtained is a known trigger of asthma.
5.2.3.3 Other Irritants hydrogen peroxide or bleach exposes children

Wood smoke from stoves, fireplaces, or barbe- and inmates of the house to high levels of irritants
cues may trigger asthma; if so, avoidance is with the risk increasing for occupations such as
required. Smoke resulting from any burning sub- house cleaners and janitors [116].
stance can also trigger asthma. Gas stoves also Lack of personal hygiene also contributes
produce irritants. VOC to indoor air.
Candles made from petroleum products can Nitrogen dioxide may be produced in the
trigger asthma. A candle produces its weight in home from poorly vented gas appliances (ranges,
soot, and its perfume can also be a trigger for water heaters, and fireplaces) and may be a fur-
asthma. ther source of triggers.
Other irritants include perfume and strong Changing weather conditions [117–120] as
odors from household cleaners and chemicals, well as changes in temperature, humidity, baro-
paints, varnishes, incense, air fresheners—even metric pressure, and winds may also be triggers,
strong cooking fumes—and scented personal as in the example of children with asthma in
care products. Aerosols produce small particles Japan mentioned earlier [98].
that are easily respirable and cause problems for
the individual with asthma. Some odors in sprays
used in the home may irritate persons with 5.3 Ingested Allergens
asthma, and these persons will generally recog-
nize this themselves. Irritants such as volatile Asthma symptoms are often attributed to foods.
organic compounds are given off by vinyl shower Many others have food-related allergies such as
curtains, hair spray, shampoo and cosmetics, eczema or anaphylaxis. Anaphylaxis is further
building materials, particle board, medium-den- discussed in Chap. 9. Atopy changes with age. It
sity fiberboard (MDF) furniture, dry cleaning flu- begins in early childhood with eczema and food
ids, adhesives, caulk, paint, solvents, stains and allergies and, later, progresses to allergic asthma
varnishes, wall and floor coverings including car- and rhinitis, though the causal relationship is
pets and underlay, laminated products, computers uncertain. This is the “allergic march” [121].
and printers, scented laundry and dish detergents, Sensitization to foods can result initially in sensi-
candles, and craft materials such as glues, perma- tization to inhalant allergens and subsequently to
nent markers, and so on. the development of asthma [122].
Use of household chemicals can also be asso- The true incidence of food allergies that trig-
ciated with wheezing. Sherriff and colleagues ger asthma is unknown, but this condition seems
measured the total chemical burden of 11 chemi- to be more prevalent in children than adults. For
cal domestic products. They found that increased example, in a study of 100 children of mean age
use was associated with both persistent and tran- 16 months, with IgE- and non-IgE-mediated milk
sient wheeze in childhood [115]. allergy [123], one child in five developed respira-
With the COVID-19, the use of hydrogen per- tory symptoms during the challenge. Yet another
oxide-based disinfectants and excessive use of study looked at 320 children and adults (aged
bleach have polluted indoor air. Hydrogen perox- 6 months to 30 years) with atopic dermatitis and
ide is less harmful than bleach. A research team possible food allergies. This was a placebo-con-
found that mopping a floor with a commercial trolled, blind food challenge. Food allergies were
hydrogen peroxide-based disinfectant raised the found in 64% of the subjects, with 25% showing
level of airborne hydrogen peroxide to 600 parts reactions involving the respiratory tract within
per billion which is 600 times the level that 2 h of exposure [124]. Furthermore, about 10%
occurs naturally in air and 60 times the maximum of occupational asthma is induced by aerosolized
level allowed over 8 h. Exposure to hydrogen food so that inhalational exposure of food aller-
peroxide can lead to eye, skin, and respiratory gens triggers about 1% of adult asthma [125].
irritation. Cleaning countertops and floors with Foods (such as eggs, milk, wheat, and fish) that
5.3 Ingested Allergens 141
cause allergic reactions in children are often the such as licorice and the glycoalkaloids (found in
cause of occupational asthma in adults [126]. green potatoes and lima beans) can also cause
Food has also been associated with epidemics of adverse reactions.
asthma—as in Spain, when aerosolized soya Thus, sensitivities to food include much more
(from containers being unloaded at a port) than allergies and more than the food itself. Food
resulted in severe exacerbations with fatalities contaminants and additives are commonly the
[127, 128]. source of trouble.
In some individuals, food can trigger an Psychological food-related disorders include
asthma exacerbation. In some cases, especially neuroses and food aversion.
those involving raw foods such as fruits and sal- Allergic reactions to food can be fast or slow,
ads, it is not the food itself that triggers the and the intensity of the reaction depends on:
asthma but the pesticides and sprays used in its
production. In other cases, it is an additive, pre- • Whether the food was touched, ingested, or
servative, or dye that is responsible for the reac- inhaled.
tion. Whatever the etiology, a food diary is • The amount of allergen exposure.
helpful in confirming such a suspicion. Allergy • The food sensitivity of the person involved.
testing for food allergens can also be helpful in
true food allergy. An allergic reaction to food can take place
The term “food allergy” is widely misused. within seconds or minutes of contact or take
Allergy is an immune-based IgE hypersensitivity somewhat longer. Some reactions may be fol-
whose symptoms can change through life stages. lowed by a “late-phase” reaction anywhere from
Many food allergies are not really an immune 6 to 8 h later.
response. Food reactions can be classified as: The starting points in identifying food aller-
gies are the individual’s self-observation and the
• Allergy. use of a detailed diary. Then, it follows a detailed
• Intolerance. history and physical examination. Finally, food
• Metabolic reaction. allergies are confirmed through skin testing, usu-
• Pharmacological food reaction. ally performed by an allergist or by blood testing
• Psychosomatic [129]. using specific IgE [132].
Foods can produce anaphylaxis, gastrointesti-
Food intolerance is a phrase sometimes used nal symptoms (vomiting, diarrhea, and abdomi-
to describe the gastrointestinal symptoms of nal pain), malabsorption, and skin problems such
celiac disease and “lactose intolerance.” There as urticaria, eczema, and so on. Foods can also
may be a superficial similarity in some symp- trigger asthma [133], and this phenomenon is
toms, but these are quite distinct conditions. seen more often in children of Asian descent,
Celiac disease (CD) is a multi-system condition with ice, fizzy drinks, fried food, and nut allergies
with autoimmune features and symptoms trig- predominating [134].
gered by ingestion of gluten in genetically sus- Common food allergens include egg, milk,
ceptible individuals [130]. Symptoms of lactose fish, shellfish, cereal grains, tree nuts, peanut,
intolerance are due to lack of the enzyme lactase soybean, and citrus foods [135]. Among nuts, the
in the bowel mucosa. There may be a genetic commonest allergy is to Brazil nut followed by
basis, or it may be acquired after damage to the almond and hazelnut [136]. 90% of infants aller-
small bowel [131]. gic to milk seem to lose their reactivity by age 3.
Some food reactions are the result of either It should be noted that any food can trigger an
natural or man-made chemicals in ingested food allergic reaction in an individual who is sensitive
(e.g., monosodium glutamate or MSG) or sub- to it. Care must be taken in diagnosis, as preser-
stances such as caffeine, histamine, theobromine, vatives and additives may be responsible for the
and toxins in mushrooms. Natural toxic agents reaction. (See Sect. 5.3.2)
One unintended consequence of dietary period of trees, grasses, and weeds. For instance,
restriction, for whatever reason, is nutritional people with ragweed and grass pollen allergies
deficiency, particularly of vitamins and minerals. will complain of oral pruritus from eating melons
This is an important reason to confirm a diagno- or bananas [139] or from drinking chamomile
sis requiring food restriction, before limiting the tea, while those with birch pollen will report
diet and removing essential nutrients. Thus, some problems with apples, carrots, and hazelnuts
individuals with food allergies will need assis- [140, 141]. This is generally a seasonal occur-
tance and advice from a dietician. rence, closely linked to the individual’s allergy.
In most cases, the allergic reaction can be pre-
vented by cooking the offending food, and they
5.3.1 Oral Allergy Syndrome can return to eating these foods once the respec-
tive pollen season is over.
Many foods by themselves will not cause a reac- Cannabis pollen is also a seasonal allergen
tion in the sensitive individual. However, when and can cross-react with fruits and vegetables in
combined with a sensitivity to seasonal inhaled what is known as cannabis-fruit/vegetable syn-
allergens, they can trigger reactions. This is drome. Sensitization to cannabis can result in
known as oral allergy syndrome [137]. About 5% anaphylaxis to fruit that used to be tolerated [81].
of children and 8% of adults suffer from this syn- As mentioned earlier, latex allergy may also
drome [138], with allergic rhinitis as a common have an oral allergy component when the person
feature. Symptoms involve the oropharynx, lip, with latex allergy ingests certain foods such as
tongue, and oral mucosa. Sometime throat pruri- avocado, banana, chestnut, grape, kiwi, pineap-
tus and/or angioedema can be present. This con- ple, passion fruit, and soybean [77]. There is a
dition is also called “pollen-food allergy.” long list of associated sensitivities to almond,
Some examples of the resulting cross-reactiv- apple, beets, buckwheat, celery, citrus fruits, figs,
ity are shown in Table 5.1. grapefruit, hazelnut, lettuce, peach, peanut, pear,
Symptoms are generally noted when raw spinach, strawberry, sweet pepper, tomato, wal-
fruits, seeds (such as sunflower and fennel), and nut, watermelon, wheat flour, and a number of
vegetables are ingested during the pollination spices [79].
Table 5.1 Seasonal allergens that can cause oral allergy 5.3.2 Food Additives
syndrome
Pollen-food cross-reactivity Food additives are used to maintain nutritive
Fruit, vegetable, or food that can cause a quality, as an aid to the processing, packaging,
Seasonal reaction in an individual with sensitivity to
allergen the seasonal allergen and storage of foods or for appearance. Regulated
Birch Apple, almond, apricot, carrot, cherry, by government agencies, they must meet strict
pear, celery, plum, peach, fennel, walnut regulations. They do not include common ingre-
and hazelnut, potato, spinach, wheat, dients such as sugar, salt, vitamins, and flavors.
buckwheat, orange, tomato, peanut, honey,
Food additives such as benzoates, salicylates,
kiwi
Grass Buckwheat, celery, potato, melon, nitrates, nitrites, sorbates, and sulfites may cause
watermelon, orange, cherry reactions including asthma exacerbations [135,
Ragweed Melon, cucumber, banana, zucchini, kiwi, 142, 143]. Some of these also occur naturally in a
chamomile, sunflower seeds, honey wide range of foods and can produce similar
Mugwort Celery, apple, carrot, peanut, kiwi,
symptoms.
watermelon, melon, chamomile, hazelnut,
parsley, spices (aniseed, cumin, coriander, There are many foods that contain naturally
and fennel) occurring benzoates. These include cinnamon,
Cannabis Cherry, hazelnut, peach, tangerine, plant nutmeg, clove, anise, prunes, tea, strawberries,
food-derived alcoholic beverages and raspberries.
Reactions to food can be the result of dyes, If someone with asthma is susceptible to these
preservatives, flavor enhancers, artificial sweet- agents, they may develop respiratory symptoms
eners, or alcohol. Monosodium glutamate (MSG) (such as wheezing, coughing, and shortness of
is a flavor enhancer; like other glutamates, it can breath), gastrintestinal symptoms (nausea, diar-
trigger headaches, asthma, flushing, and gastro- rhea, abdominal pain), flushing, light headed-
intestinal symptoms. Tomatoes, mushrooms, and ness, laryngeal edema, dizziness, urticaria,
cheese have naturally occurring glutamate simi- angioedema, onset of hypotension, a feeling of
lar to MSG. temperature change, seizure, and death [149].The
Tartrazine or Yellow FD&C #5, so labeled by symptoms are different from those who have
the US Department of Agriculture (USDA) to allergic reactions to foods. Fatal anaphylaxis is
comply with the Food, Dye and Coloring Act, is possible [150].
not a common food allergen yet is an asthma trig- Sulfite sensitivity is seen in adults more than
ger [133]. Tartrazine, a yellow dye which can in children and in women more than men.
produce bronchoconstriction, is used in food, Once food sensitivity is suspected, then a
medication, candies, and soft drinks. Sunset detailed history should be taken of the circum-
Yellow #6 has been linked with gastrointestinal stances under which symptoms occur, and this
allergies. should be supplemented in some cases with a sul-
fite challenge in the laboratory.
5.3.2.1 Sulfites
Sulfites (including bisulfite and metabisulfite) are
among the most common additives. They were 5.4 Non-allergenic Triggers or
once used in restaurants as preservatives to help Irritants
foods and vegetables maintain a crisp and fresh
appearance. (This is no longer allowed in the Allergen-induced reactions occur only after a
USA.) They delay bacterial spoilage and minimize latent interval following exposure. That is, they
discoloration of many different foodstuffs. They require prior sensitization and some period of
are commonly used in manufactured food [144]. time before a reaction can be induced. Reactions
Reactions may occur when a food containing can occur at very low exposure levels, and symp-
sulfites is ingested. Sulfites are found in pro- toms may present early or late. In both cases, this
cessed potatoes, dried fruits, beer, hard cider, is known as a delayed response.
fruit and vegetable juices, and tea. They also Irritants do not require previous exposure.
occur in wines and beer, although sensitivity to Reactions tend to be immediate and resolve
these drinks may be associated with substances within minutes or hours of exposure. However,
other than sulfites [145, 146]. They are also to be repeated exposure to allergens can result in
found in baked goods, condiments, glazed fruit, heightened sensitivity in target organs (such as
jam, pickles, gravy, molasses, shrimp, and soup the nose and lungs), making them more respon-
mixes [147]. Since 1993, sulfites at concentra- sive to irritants.
tions of 10 ppm (parts per million) or more must
be listed as an ingredient even if used as a preser-
vative. They are used in some medications, such 5.4.1 Cold Air
as a beta-adrenergic agonist, in some nebulizer
solutions, and in some forms of injected epineph- This is a common trigger of asthma in certain
rine [148]. All of the sulfite agents may release parts of North America, and the trigger mecha-
sulfur dioxide under suitable conditions, which nism is similar to that for exercise. This is a spe-
may be breathed in by the individual with asthma cific problem in cross-country skiers and often
and thus lead to an exacerbation. under-diagnosed [151].
5.4.2 Exercise susceptibility to rhinovirus infection [155, 156]. It

is not known if this occurs in childhood.
Exercise has been discussed in Chap. 4. Viruses vary in their ability to produce wheez-
ing, with rhinovirus and RSV (respiratory syncytial
virus) being particularly potent inducers of wheeze.
5.4.3 Emotion Generally, the asthma exacerbation occurs after 1
or 2 days of a cold and possibly continues for sev-
Emotional factors are important in asthma, as eral weeks. It is impossible to totally prevent the
they are in coping with any chronic disease. It is spread of the common cold, but the risk can be
not clear whether emotion itself triggers asthma reduced by avoiding crowded environments, by
or if the mechanism is more complex. For exam- handwashing and disposal of tissues, etc. Children
ple, emotional problems may exacerbate a pre- have more frequent viral infections in daycare.
existing condition and make it more difficult to Therefore, those children with asthma who attend
adhere to advice. In some cases (when crying or daycare will have more frequent exacerbations.
sobbing, e.g.), hyperventilation will induce Viral infections have been considered initiat-
asthma with a physical mechanism similar to that ing factors for asthma, and paradoxically, it has
of exercise or cold air. also been suggested that they may protect against
Other mechanisms may exist that induce asthma. This complex topic is mentioned in
asthma in the presence of more severe and con- Chap. 1, and it should be recognized that specula-
tinuing stress. With major stress or emotional tion is concerned only with the role of viral infec-
upset, it can be difficult to fully adhere to tion in the onset of asthma. There is no speculation
“unpleasant” asthma-related advice, particularly on the proven role of viral infections in triggering
when it involves removing pets or modifying an attacks in established asthma.
exercise routine. Often, advice for the individual
affects the family too.
Asthma exacerbations have been linked to 5.4.5 Medication Sensitivity
periods of heightened emotion and stress [152,
153]. Even individuals without asthma have Medications, even some used in the treatment of
shown an increase in bronchomotor tone when asthma, can also be a trigger of asthma. Beta-
exposed to stress and a reduction when exposed agonists or relievers can actually trigger broncho-
to relaxing stimuli [154]. Negative emotions may constriction in certain genotypes. Excipients are
exacerbate asthma [152]. the usual cause of reactions [157]. For some indi-
Finally, many individuals with “emotionally viduals, the preservative benzalkonium chloride
triggered asthma” have vocal cord dysfunction which is added to beta-agonists can trigger
(VCD). This is a disorder distinct from asthma asthma symptoms. The dyes and preservatives
and also distinct from panic attacks. It should be used in formulating a drug can also trigger an
noted that about half of those with vocal cord exacerbation. See also Sect. 8.11.
dysfunction also have asthma. VCD is further Over-the-counter (OTC) medications are
discussed in Chap. 9. those that do not require a prescription. Many of
these may increase asthma sensitivity.
Acetaminophen (Tylenol) is usually considered
5.4.4 Viral Infections safe although there are rare cases where it does
increase sensitivity. Aspirin, however, may cause
Viral infections are a common trigger of asthma at problems for individuals with asthma. There may
all ages. They are particularly prominent in child- be an association between aspirin sensitivity
hood because of the frequency of viral infections. (aspirin or acetylsalicylic acid—ASA), asthma,
They increase airway injury by promoting airway sinusitis, and nasal polyps, although this is not
inflammation. In adults, chronic stressors increase invariable [42].
Many individuals with asthma purchase OTC cation has a new excipients or the reaction is
medications for relief of pain, cold, and flu symp- unrelated to the medication. The first of these is
toms, and many of these contain aspirin. Thus, easy to deal with using Internet searches. The
OTC medications may be a source of danger. All second possibility, that symptoms are unrelated
purchasers, whether or not they have asthma, to the medication, is a situation in which clarity is
must examine the small print carefully to ensure very difficult to achieve. A very detailed history
that the ingredients are safe. It should also be is needed, but the person, who blames the medi-
suggested to them that it is better to purchase cation, may be unwilling to consider any other
remedies from a pharmacy, where professional possibility. However, in dealing with an anti-
advice may be obtained from the pharmacist, asthma preparation, substituting an alternative is
than from a grocery or convenience store. See usually straightforward.
“Over-the-Counter Medications” in Chap. 8. Some medications have an increased inci-
All medications may cause side effects of dence of reactions in individuals with asthma.
which 5–10% are allergic [158]. Reactions may Aspirin (ASA) is one such medication. While not
occur immediately, but may be delayed up to everyone with asthma will be sensitive to aspirin,
6 weeks. The most severe allergic reactions as a general rule, it should be avoided in those
include anaphylaxis (see Chap. 9), but skin rashes with asthma. This caution applies also to other
are common. Some of the side effects, as men- medications known to produce reactions, such as
tioned earlier, may be due to substances other the non-steroidal anti-inflammatories or NSAIDs
than the medication itself (i.e., excipients). New [159, 160]. Care should always be taken in their
symptoms may be attributed to a medication in use and especially so if any sensitivities exist.
use for months or years, and indeed the medica- Medications in this category include aspirin, ibu-
tion may be the cause. However, the educator profen, indomethacin, naproxen, mefenamic
should explore two major possibilities: the medi- acid, etc. See Figs. 5.1 and 5.2. Brand names that
Partial List of Over-The-Counter medications containing ASA (acetylsalicylic acid) also known as Aspirin
Advil Coricidin Momentum

Alka Seltzer Coryphen Neo-Tigol
Anacin Dolomine Nervin
Ancasal Dristan Neurophen
Antidol Ecotrin Norgesic
Arthrisin Empirin Novasen
Asaphen Entrophen Novo AC&C
Ascriptin Excedrin Pepto-Bismol
Aspergum Fernol Tri-Buffered ASA
Aspirin Herbopyrine 217, 217 Strong
Astrin Instantine 222
Bayer Coricidin Cold Kalmex 222 Forte
Bufferin Lemon Time Vanquish
Calmine Mido Vita
Fig. 5.1 OTC medications with ASA that have an adverse effect on asthma. (Other products with “ASA,” “APC,” or
“PAC” in their name also contain aspirin)
include the letters “ASA,” “APC,” and “PAC”

Partial list of contain aspirin.
PRESCRIPTION The beta-blockers used as eye drops
(Timoptol), or for heart disease or hypertension,
medications containing have the opposite effect of the beta-agonists used
ASA (acetylsalicylic acid, to treat asthma and thus may cause or exacerbate
asthma. (See Table 5.2). Other medications such
also known as Aspirin) as angiotensin-converting enzyme (ACE) inhibi-
tors, which can trigger asthma, are listed in
Table 5.3.
Achrocidin
Asacol
5.5 Exposure Reduction
Asasantine and Avoidance Techniques
Darvon All asthma guidelines [161–164], including
Endodan NAEPP; the National Asthma Education and
Prevention Program sponsored by the National
Equaqesic Heart, Lung, and Blood Institute (NHLBI) of the
National Institutes of Health; and the most recent
Florinal
2020 Focused Update [163], stress that one of the
Percodan goals of good asthma management should be the
avoidance of environmental allergens, both
Phenaphen
indoor and outdoor. Avoidance of allergens [6,
PMS 130] is an essential component of the manage-
ment of asthma. It is not yet clear which individu-
Robaxinsal
als will benefit from such avoidance and how
Salofalk great the benefit will be [165]. Teaching them
how to avoid these allergens is essential if they
Salzopyrin are to learn how to control asthma. It is important
SAS
to realize that if there are symptoms, and it is
clear that allergens are causal, or there is proven
Sulfasalazine sensitization to an allergen, then a multi-pronged
approach has to be taken to reduce that allergen
Technal
exposure. This holds true of all the asthma-induc-
Trilisate ing allergens.
282, 292, 293,692
5.5.1 Pollen
Fig. 5.2 Prescription medications with ASA that have an Individuals with asthma should ideally be aware
adverse effect on asthma. For a more detailed list of both of the particular pollens—grasses, weeds, or
prescription and non-prescription drugs containing aspi-
rin, see https://my.clevelandclinic.org/ccf/media/files/ trees—that trigger their asthma and their sea-
Florida/Gynecology/6-medicationlist.pdf sonal prevalence. Once this is known, avoidance
Table 5.2 Beta-blockers and NSAIDs that may have an adverse effect on asthma [159]
Type of medication Trade names
Beta-blockers (These medications Betoptic Coreg Normodyne Toprol
are used in the treatment of high Betapace Corgard Tenoret Visken
blood pressure, angina, and Biocadren Inderal Tenormin
glaucoma) Brevibloc Lopressor Trandate
Cartol Levatol Timoptic
Non-steroidal anti-inflammatory Advil Darvon Indomethacin Orudis
drugs (NSAIDs) prescription and Actiprofen Daypro Ketoprofen Oruvail
OTC Aflaxen Diclofenac Lodine Percodan
Aleve Disalcid Lortab Piroxicam
Alka-seltzer Dolobid Medipren Ponstel
Alor Dristan Meclomen Relafen
Anacin Easprin Menadol Robaxisal
Anaprox EC-Naprosyn Methocarbamol Rufen
Ansaid Ecotrin Midol Soma
Arthrotec Endodan Mobic Sulindac
Aspirin Equagesic Morin-1 Synalgos
Bayer Excedrin Motrin Talwin
BC Feldene Nalfon Trilisate
Bufferin Fiorinal Naprelan Toradol
Butalbital Flurbiprofen Naprosyn Tolectin
Butazolidin Goody’s Naxen Vicodin
Carisoprodol Halprin Norgesic Vicoprofen
Cataflam Idomed Novo-Methacin Vioxx
Celebrex Ibuprofen Novo-Profen Voltaren
Clinoril Indocin Nuprin Voltarol
Table 5.3 Medications that have an adverse effect on tronic systems. They should minimize their expo-
asthma [159, 256] sure by staying indoors, preferably in an
Type Name air-conditioned environment, and avoid activity
Analgesic Pentazocine (Talwin) and exertion at midday and in the afternoon when
Angiotensin- Lisinopril (Zestril) enalapril pollen counts are high.
converting enzyme (Vasotec)
inhibitors (ACE)
Allergies to weeds require avoidance of other
Antiarrhythmic Procainamide (Procamide) related members of that particular family. For
Antibiotics Cephaloridine erythromycin instance, ragweed is related to asters, chrysanthe-
griseofulvin nitrofurantoin mum, dahlias, goldenrod, and marigolds. A per-
Penicillin streptomycin son allergic to ragweed would be wise to avoid
tetracycline
Anticonvulsant Carbamazepine (Carbatrol)
contact with these flowers and chamomile teas.
For colitis Sulfasalazine (Azulfidine) Flowering plants should not be kept in the
For ulcers Cimetidine (Tagamet, Zantac) bedroom. Prior to bedtime, those with asthma
Others Dextrans; iodine-based contrast should shower and wash their hair and change all
media; dyes and preservatives their clothing. This prevents pollen that was
used in formulations; pituitary
brought indoors on hair and skin from being
snuff, mineral oil
transferred to bedding, which could then act as an
allergen reservoir. Those with severe sensitivity
should change their clothing and bathe as soon as
measures can be taken. These would include they return indoors.
keeping windows in cars and homes closed dur- They should also be reminded not to dry
ing the pollen season and the use of special air- washed clothing out of doors. Many patients feel
conditioning and air filtration systems, such as better when they have to go out, if they wear a
high-efficiency particulate arrest (HEPA) or elec- mask with a charcoal filter (such as a Respro
mask) that prevents inhalation of pollen and other is helpful to use a mask while removing mold. Do
fine particles. Many of these masks are sold in not use bleach since it reacts with ammonia to
sporting goods or hardware stores. Patients produce toxic fumes. Discard items that cannot
should be encouraged to plan outdoor activities at be cleaned [166]. Fix any plumbing leaks. Keep
times of least pollen exposure, generally in the the bathroom light on for as long as possible
late afternoon or after a rain shower. since mold prefers the dark.
Those who are sensitive to pollen should wear Calcium chloride, available at hardware
glasses outdoors and clean their contact lenses stores, can be used to reduce moisture that leads
frequently. They should also stay indoors on to the development of mold in closets. The cal-
windy days. cium chloride will absorb moisture.
Those who are sensitive to pollen may think of Throughout the living space, the use of humid-
moving to a different area. Typically, relocation ifiers should be discouraged. Where required
does not help since pollen and fungal spores are because of high altitudes or in areas of excessive
mixed throughout the atmosphere and moved by dryness, they must be cleaned weekly to prevent
wind for great distances. Even if moving reduces the growth of fungi. Fungicides can be added to
exposure to a particular allergen, the allergy- refrigerator drip pans and water holding tanks.
prone person is likely to have now added new Clothes should not be air-dried indoors. Moisture
sensitivities to more plants. and steam from cooking should be vented to the
Pollen counts for various areas are available outside, as should clothes dryers and bathrooms.
on radio, television, or the Internet. Patients Entrances and other areas through which water
should monitor local pollen counts to minimize can seep into the house should be waterproofed.
contact. The Weather Channel has an app that Every effort should be made to limit moisture and
displays the pollen count in a particular area. humidity and to avoid or limit the number of
houseplants.
5.5.2 Mold 5.5.2.1 Outdoor Mold

Individuals with asthma should avoid yard work
There is no “mold season.” Mold is ubiquitous. such as raking, mowing grass, composting, etc.
The best detector for mold is the nose. When The amount of vegetation around the home
dealing with mold, reduction in indoor humid- should be limited [164]. Keep windows closed,
ity levels is of paramount importance. Mold and use screen filters and an air conditioner to
growth is directly related to humidity: the reduce exposure to outdoor molds [167].
higher the humidity, the greater the chance of However, in the interests of fairness and peace,
mold occurring. Use of a dehumidifier should there may need to be some negotiations within
be recommended in humid locations. Also help- families to allow the family member to undertake
ful are the removal of mold (especially plant other tasks as a compensation.
soil), the application of retardant solutions in Automobile air conditioners are a further
damp areas, and the use of air filtration sys- source of mold and of several species of fungi
tems. Springtime, when the snow melts, is often such as Alternaria, Cladosporium, Penicillium,
a time when increased numbers of mold spores and Aspergillus [168]. Some manufacturers pro-
escape into the air. So-called snow mold is a vide replacement filters since decontamination is
potent allergen. This same mold also occurs in not easy. If the inside vent filters are not changed
autumn. regularly, then use the air conditioner in recycling
Indoor mold can be reduced in bathrooms by mode when traveling in the car.
scrubbing with detergent and water on hard sur- Do not park the car outside during pollen sea-
faces such as tiles and fixtures. They must be son since pollen enters the car when the door is
dried thoroughly after cleaning. Frequent clean- opened. Wipe car door handles before getting
ing and the use of a fan will help to limit mold. It into the car to minimize exposure.
5.5.3 Dust and Dust Mites of the asthma [163]. In general, appropriate vacu-
uming can be difficult. Many domestic models
Anyone who has asthma should be encouraged to will discharge a fine (and invisible) spray of aller-
reduce exposure to house dust mites (HDM) by genic dust from the rear at the same time the front
[6, 165, 169]: is picking up larger particles of dirt. A built-in (or
“central”) vacuum cleaner is superior, but an
• Maintaining indoor humidity at 35–50%. equally good alternative is a HEPA vacuum
• Encasing mattresses, pillows, and box springs cleaner. If that is not possible, then using two- or
in allergen- or dust-proof casings [37, 152, three-layer vacuum cleaner bags will reduce the
162, 170, 171]. amount of dust and dust mites [174]. A study at
• Replacing foam mattresses with spring mat- the University of Virginia proved that multi-layer
tresses [8]. bags, when combined with microfiltration in
• Removing carpets, particularly from bed- medium-priced vacuum cleaners, proved to be a
rooms, and using hardwood or vinyl flooring very effective method for reducing dust mite
instead. allergen [175].
• Removing upholstered furniture from the Air filters are widely used, but there are few
bedroom. well-controlled studies of their effectiveness. In a
• Minimizing clutter. systematic review, ten randomized controlled
• Limiting the number of stuffed toys to those studies were identified. In these studies, use of air
few that can be washed in hot water. filters was associated with lower symptom scores
• Removing bookcases and shelving that collect and lower sleep disturbance, but no difference in
dust. medication use or morning PEF was noted [176].
• Storing only currently used clothing in the While acaricides such as benzyl benzoate and
cupboard. pirimiphos-methyl can help reduce HDM levels,
• Removing all wall hangings and dust the removal of reservoirs of HDM allergen is
catchers. more effective and simpler than treatment.
• Removing blinds and drapes and replacing Acaricides are expensive and potentially toxic
them with washable curtains and blinds that and should not be used when children are in the
can be wiped. room [169, 177]. Use of acaricides is a very slow
• Using a damp cloth for dusting, so that dust process and does not kill all dust mites, particu-
particles are trapped, rather than moved about. larly those in carpet underlay. Repeated applica-
• Using air filtration systems [170, 172]. tion and vacuuming will reduce the HDM level
• Regular vacuuming with adequate HEPA fil- [28, 178]. A 3% tannic acid solution is minimally
tration or one that vents to the outside [173]. effective at reducing HDM levels in carpets, soft
• Washing all bed clothes weekly in cold water. furnishings, and upholstered furniture and hence
• Avoid using a 3% tannic acid spray for carpets is not recommended [169].
and upholstered furnishings since it is only Some persons with asthma may feel that buy-
partially effective. (These products are avail- ing a new mattress or pillows will alleviate the
able in stores that sell allergy-related products, problem of dust mites. Alas, relief is short lived.
under names such as Allersearch, Allersearch In less than 4 months, a new mattress will have
ADS, and DustMitex, to name a few.) reached the allergen level of an old mattress
• Avoid sleeping in bunk beds—if it cannot be [179]. Allergen-proof casings for mattresses and
avoided, the atopic child should sleep on the pillows are extremely effective in reducing aller-
top bunk bed. gen exposure for sensitive persons. Further, the
use of bedding encasements that block HDM has
However, all this involves a great deal of effort been found to prevent sensitization to HDM in
and attention to detail. The extent of preventative atopic infants [180]. Changing from a foam mat-
activities should be proportionate to the severity tress to a spring mattress may also be helpful. In
a study of 152 homes, mite feces were found in of furnace filters will decrease the amount of
41% of foam mattresses without covers, 26% of dust that is circulated. The addition of an elec-
foam mattresses with covers, and only 12% of tronic air filter on the heating/cooling system
spring mattresses [172]. will further reduce dust levels. These precau-
Non-woven synthetic fabrics are less expen- tions appear reasonable though there are no
sive but not as effective as microdenier fabrics in clinical studies to confirm that this type of addi-
excluding both cat and dust mite allergen. tional cleaning will result in a reduction of
Fabrics with an average pore size of less than 10 asthma symptoms. Of course, persons allergic
microns block HDM, while those of 6 microns to dust should not be present when ducts are
or less block cat allergen [175]. Covers should cleaned.
be easily fitted, cleaned, and sturdy enough to For those items that are difficult to wash in hot
endure repeated washing, since allergens will water, an alternative exists. Soft toys can be put
accumulate both on top of and inside the casings in plastic bags, sealed, and placed in a freezer for
[28]. Vinyl covers are noisy, hot, clammy, and 24 h once a week. The toys should be vacuumed
uncomfortable because they are impermeable to to remove any allergen before being returned to
air; they are hence not recommended. However, their owner.
where limited budgets make them the only solu- Curtains or shades should be washed or
tion, they can be used. They can also be used in cleaned once a week.
cases of enuresis (bed-wetting). A washable mat- While the bedroom of the allergic person
tress pad placed on the vinyl cover and under the should contain the minimum of furniture, it can
bottom sheet will make for increased comfort. avoid looking like a bare cell. Children should
Bedding should be washable and should be see their bedroom as a haven, not a punishment.
washed once a week. Blankets should preferably As such, favorite toys and books can be kept in
not be of wool. Washing in cold water drowns the the room in clear, covered, see-through plastic
mites and can remove 80–93% of the mites from containers that prevent dust from gathering on
bedding [167]. There are no detergents or laundry the toys/books and can easily be wiped clean.
products that are effective in killing them. Dry The advantage of this is twofold: the child,
cleaning does not reduce the allergen concentra- firstly, does not feel deprived and, secondly,
tion, though it does kill the dust mites. learns to put away the toys and books when done
Feather pillows can be a problem if there is a with them.
specific allergy to feathers. While feather pillows The older allergic child can help in cleaning
have long been considered to be filled with dust the bedroom provided they wear a mask. The
mite allergen, studies in New Zealand appear to room should be left unoccupied for half an hour
indicate that synthetic pillows actually have 12 to allow airborne allergens to settle.
times as much allergen [181]. Newer types of Consumers of allergy control products should
synthetic pillow coverings have the same perme- be made aware that many manufacturers’ claims
ability to live HDM and house dust as feather pil- are not scientifically proven. Nor do many of
lows [181]. The processing of feathers removes them state how effective or cost-effective their
all dust mite allergen, and generally the weave of products are. Often, product life and casing pore
the casings is too tight to allow feathers to escape size are not mentioned. Hence, caution must be
or dust mites to enter. Standard synthetic pillows used in employing these products [184].
acquire dust mite allergen (Der p 1) more rapidly A single approach to handling dust mites,
than do feather pillows [182, 183]. Regardless of such as only using pillow and mattress covers,
the type of pillow, allergen-proof covers are will not suffice. If the person has symptoms due
recommended. to dust mites or is sensitized to them, then multi-
In homes with forced air heating, yearly ple approaches have to be taken to reduce aller-
cleaning of ductwork and regular replacement gen exposure [163].
5.5.4 Cockroach Allergen • Ensuring that microenvironments that can

shelter cockroaches are eliminated.
Cockroaches are difficult to eradicate. They are • Cleaning and removing reservoirs of cock-
ubiquitous being found in schools, grocery roach allergens.
stores, places of worship, and homes, to name • Sealing and caulking cracks and holes on the
just a few locations. They are generally associ- house/building exterior.
ated with inner-city multi-family housing, but • Installing door sweeps and weatherproofing
have also been found in suburban dwellings seals on exterior doors.
[185]. Cockroach allergen is even found in bed- • Installing screens and weather proofing win-
ding, having been brought in on clothing and on dows and attic vents.
the feet. • Placing stoppers in all sinks and drains.
The allergen is difficult to remove because • Moving lumber, firewood, and trash cans
roaches cluster in narrow cracks and crevices, away from the house/building.
making removal difficult. It can, however, be • Maintaining gutters and keeping them clean.
reduced by [186, 187]:
Devices that produce ultrasonic sound waves
• The use of bait traps (such as Combat) that are do not have any effect on cockroaches since they
replaced every 3 months. cannot detect ultrasonic sound waves [187].
• Aggressive extermination of cockroaches in It may require a team involving social ser-
the dwelling (while ensuring that the person vices, the landlord, and the public health nurse to
with asthma stays elsewhere during the pro- work together to eradicate cockroaches in multi-
cess and until the place is aired out). unit urban dwellings.
• Storing food in airtight containers. Cockroaches are generally nocturnal, prefer-
• Eating only in one place, preferably at the ring to move around in the dark. If they can be
kitchen/dining table, and not on the couch in seen during the day, then there is an infestation,
front of the television. and professional help is required to get rid of
• Putting food away as soon as the family has them. Professional eradication is the best method
finished eating. of getting rid of cockroaches. Professional appli-
• Wiping up spills promptly. cation of insecticides (such as hydromethylnon,
• Emptying drip pans of frost-free fipronil, or sulfluramid) has been found to be
refrigerators. effective in reducing the allergen level by 80–90%
• Covering moist plumbing pipes with [188, 189]. The new gel baits are more effective
insulation. than the organophosphates. Sodium hypochlorite
• Increasing ventilation to reduce moisture. is not helpful. Boric acid is safe but less effective
• Daily removal of garbage. [188]. Thereafter, every effort must be made to
• Avoiding storage of brown paper bags and provide an environment that is not hospitable to
cardboard boxes. cockroaches. This includes removing food and
• Careful conscientious regular cleaning of the water from pet feeding bowls overnight and
kitchen, bathrooms, and basements. replacing them in the morning.
• Regular vacuuming of bedrooms and all As with cat allergen, it takes about 6–8 months
upholstered furniture (see previous cautions of cleaning to remove residual roach allergen in
on potential problems with conventional homes [187, 188, 190].
vacuums).
• Professional integrated eradication using pes-
ticides [187]. 5.5.5 Pet Allergen
• The use of boric acid—though any cock-
roaches that survive may produce even more Warm-blooded pets should not share living space
allergen [186]. with a person for whom pets are a trigger for
asthma. While this statement is almost always • Encasing mattress, pillows, and box springs in
true, and the advice should be followed whenever allergen-proof casings.
possible, there can be slight modification in spe-
cific circumstances. Pets are commonly present Permitting cats to spend time on furniture
in households of those with asthma, and families along with low ventilation rates result in increased
are reluctant to consider any different arrange- levels of cat allergen. Ideally, if the pet can be
ment. Pets may be one of multiple and varied looked after elsewhere, and there is aggressive,
exposures, each requiring specific and different thorough, and repeated cleaning of the home,
approaches. For example, it has been shown that there will be a fall in allergen levels. This will
smoking and pet ownership are not correlated never be as much as one would like, and some-
with one another, but relate in opposite ways to times the fall is disappointingly low. Even with
socioeconomic status, pet ownership being asso- the removal of the cat and stringent, professional
ciated with greater resources than smoking. Thus, cleaning methods, it takes at least 20–24 weeks
counseling strategies will need to be independent before the level of cat allergen drops to the level
of one another [101]. found in homes without cats [193, 194].
The allergen from cats and dogs are dispersed Cat allergen is readily transported on hair and
into the environment by pet saliva, hair, and clothing, particularly on woolen and synthetic
urine. These allergens are easily aerosolized and fibers [195]. This explains the high levels of pet
remain airborne for long periods of time. They allergen found in schools and other public places
accumulate on carpets, upholstery, bedding, and where cats are normally not permitted and why
other soft surfaces including beds and also where symptoms will persist despite strict avoidance
pets sleep and rest. measures taken at home. To minimize exposure
Avoidance is the best and most effective way to cat allergen, the sensitive individual should
to avoid both dog and cat allergens. Individuals change their clothes when moving from a high
with asthma should seriously consider removing cat allergen environment to a low cat allergen
the dog and/or cat permanently from their envi- environment [54].
ronment for their own respiratory health. If that Keeping the cat out of the bedroom may
cannot be done, then exposure to the pet allergen reduce allergen levels there. Even this is doubtful
can be minimized by using the following mea- in homes with forced air heating as its small par-
sures that will help a little in reducing exposure ticle size leads to dispersion of the allergen
to pet dander [191]: throughout the home, even in rooms the cat has
never entered. The allergen level is highest where
• Keeping the pet out of the bedroom of the per- the cat spends most of its time, but levels are not
son with asthma. negligible in other rooms.
• Thorough cleaning of the bedroom [56]. Washing with water is as effective [196, 197]
• Removal of all upholstered furniture and car- as most comercial products for reducing both cat
peting from the bedroom. and dog allergen. The person with sensitivities
• Washing the pet at least once a week. should not wash the pet. Twice-weekly washing
• Washing hands after touching the pet. of the pet will reduce cat allergen [52] as will
• Increasing ventilation [56]. washing of the clothing of cat owners. This will
• Using a room air cleaner that has a HEPA also reduce and prevent dispersal of the allergen
filter. [198]. Tannic acid, even as a 1% solution, when
• Using either a vacuum cleaner with a HEPA used for cleaning carpets, drapery, and uphol-
filter [192] or a central (“built-in”) vacuum stered furniture, may reduce cat allergen levels,
system with the dust collection device located though the presence of cat allergen itself will par-
outside the house. tially block the effectiveness of tannic acid [199].
5.5.6 Rodent Allergen Table 5.4 Other names for some common food
allergens
Mice enter homes through cracks and holes in the Food

item Other names for the food item
foundation, floors, and walls; through gaps in
Egg Albumen, globulin, ovavitellin, dried egg,
windows and ceilings; and through sewer, gas mayonnaise, silici albuminate, ovomucoid
lines, and plumbing. While integrated pest man- Milk Evaporated milk, condensed milk, milk solids,
agement is helpful in reducing both rat and mouse milk powder, butter, buttermilk, yogurt, curd,
allergen, it needs to be supplemented with: cheese, cottage cheese, cream cheese, cream,
sour cream
Corn Tacos, tamales, nachos, popcorn, masa harina,
• The sealing or closing of any wall or floor maize, hominy, tortillas, grits, corn flour
openings.
• Plugging cracks with steel wool mixed with
caulking compound or expandable spray food—such as paper plates and paper cups—are
foams and gels. often coated with corn starch to prevent sticking.
• Use of baits and traps that are set close to Information on specific allergens and their
walls or behind objects or where there are labels can be obtained from a reputable food
signs of mice. allergy association such as the Food Allergy
• Good sanitation. Research & Education (website: www.foodal-
• Storage of food in airtight glass or metal lergy.org). Refer to Fig. 5.3, “Resources,” for
containers. phone numbers to call.
• Disposal of food waste as quickly as The person with food allergies must:
possible.
• Avoid any food whose ingredients are in doubt.
Ultrasonic devices that claim to kill rodents • Know the various names that indicate the
are only effective for a short time since the presence of a suspected food item or
rodents quickly get used to the sounds generated ingredient.
and then ignore them. • Re-check ingredient lists often, preferably
each time a food product is purchased, since
ingredients in products often change without
5.5.7 Food Allergen warning.
• Carry emergency medications (see Chap. 9)
Food can be a trigger for asthma in a small per- such as an epinephrine autoinjector and an
centage of individuals with asthma. For them, antihistamine.
avoidance of the offending food is the best rule. • Be doubly vigilant when eating in a
However, elimination of any food group from a restaurant.
diet must be done only after consultation with a • Remember that ingredients listed as “natural
physician or healthcare provider and a dietician. flavoring” may include milk products and
Avoidance also requires knowing the many hydrolyzed proteins.
names under which a food can be labeled. Shown • Be aware of the nutritional consequences of
in Table 5.4, for example, are some common food omitting specific nutrients from the diet.
allergens and the many names under which they
may be present in prepared foods. If the food allergy is severe, wearing a bracelet
Most commercial baking powders contain that identifies the problem is helpful. Having a
egg. “buddy” system where a friend knows what the
Individuals with allergies to corn should be problem is and can take appropriate action is very
warned that many medications include corn starch helpful, particularly for adolescents who tend to
as a binding agent and corn syrup as a sweetener avoid disclosing personal health problems. See
and that paper products intended for use with Anaphylaxis in Chap. 9.
Fig. 5.3 Resources for Allergy Control Products . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-ALLERGY

persons with allergies
www.allergycontrol.com
American Academy of Allergy Asthma and Immunology . . 414-272-6071
www.aaaai.org
American College of Allergy Asthma and Immunology . . . . 800-4278-120...
www.acaai.org
Asthma and Allergy Foundation of America . . . . . . . . . . . . . 800-727-8462
www.aafa.org
Food Allergy Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-929-4040
www.foodallergy.org
Allergy and Asthma Network Mothers of Asthmatics . . . . . . 800-878-4403
www.allergyasthmanetwork.org
National Heart, Lung, Blood Institute Information Center . . . 877-NHLBI4U
www.nhlbi.nih.gov
National Jewish Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-225-5654
www.nationaljewish.org
Also Local chapters of the American Lung Association
Local support groups
5.5.8 Medications People often view OTC medications as not impor-

tant, as not relevant, and, sometimes, not even as
Allergy to asthma medications is rare, although it “real” medication. However, OTC products can
may occur. A reaction will, in all likelihood, be interact and interfere with asthma medication, so
caused by the many excipients that are added to the it is important to be aware of them.
active ingredient. These can include lactose, potato
starch, cornstarch, soy lecithin, colorings, and fla-
vorings. Use of standard reference texts can help 5.5.9 Insect Allergen
identify triggers. Individuals with asthma and/or
allergies should be encouraged to discuss this with Obviously, the best defense against insect aller-
their healthcare provider and pharmacist. gens is avoidance. However, persons with severe
Individuals with asthma should be reminded to reactions to insects (such as bees, wasps, hornets
keep a careful record of all medication that they and fire ants) should consult an allergist about
take, including the dosage. The list should include immunotherapy. This is the recognized treatment
all over-the-counter (OTC) medications, vitamins, for insect allergy without the controversy that
birth control pills, and all medications taken for exists with immunotherapy in other situations.
other ailments. In addition, the list should include Other measures that can be taken involve:
any herbal, food supplement, or “natural” prod-
ucts. Such products may interact with other medi- • Learning to recognize which insect is the
cation and may also be the source of allergic cause of the problem [141].
reactions. Too often patients interpret the doctor’s • Avoiding areas around garbage cans and
question “What medications are you taking?” to dumpsters.
mean “What asthma medications are you tak- • Not eating outdoors.
ing?”. As a result, they omit essential information. • Use of insecticides (such as Raid).
• Not going barefoot. Avoidance is the key measure with ladybugs.

• Wearing light-colored clothing with long All cracks and crevices around doors and win-
sleeves and long pants. dows and in exterior walls of the house should be
• Staying away from hives and nests. carefully sealed. Prior to the start of cold weather,
• Not picking fruit. the outside of the house should be treated with
• Not drinking from cans. pyrethroids. Painting the exterior of the house a
darker color does not help [71].
If there are nests or hives around the home, it is Once inside a house, it is difficult to get rid of
advisable to have them removed by a professional, the ladybugs. Regular cleaning and vacuuming
thereby minimizing the possibility of exposure. with a crevice tool will help reduce the allergen
People with severe reactions to insects should load. If the house is infested, professional help to
carry an epinephrine injector (see Chap. 9). exterminate them should be sought.
Case Study
5.5.10 Irritants
Paula has asthma. She says that there is no
need to get rid of her cats since her allergy All tobacco smoke should be avoided. This is
test showed only a small positive result to particularly difficult for the child who has a par-
cats. She even gave her cats away for ent or other family member who smokes.
2 weeks and found no improvement in her Exposure to environmental tobacco smoke results
asthma. How do you proceed? in a threefold increase in nocturnal symptoms
Cat dander is highly allergenic and a among children with asthma [200]. Smoking in
trigger for asthma. Explain to her that she another room of the house does not help if the air
is allergic to cats and that the small size of in the home is circulated through ducts from a
the positive test does not indicate a “small” central heating or cooling system. Smoking out-
allergy. The continued presence of cat dan- side the home reduces the level of exposure, but
der will contribute to the deterioration in it should be remembered that the smoker, on
her asthma. Furthermore, giving the cats coming back into the home, brings in traces of
away for 2 weeks will not reduce the level tobacco smoke on hair, skin, and clothing.
of dander in her home. It takes at least a Smoke from fireplaces and wood-burning
couple of months of intense cleaning to get stoves and fumes from kerosene stoves and space
rid of all the cat dander in the home. For her heaters are all known triggers of asthma. These
future well-being and to control her asthma, should be avoided. Stoves that use natural or bot-
it would be preferable if she did not have tled gas are generally not a source of irritants and
cats in her home. do not affect respiratory symptoms or pulmonary
It can be more difficult to give advice if function [201]. All pilot lights on gas appliances
the test is completely negative. The action should be checked regularly.
taken will probably depend on the severity Perfume is also a trigger. There are a number
of the asthma. Only if she has severe of scented products—air fresheners (solids, gels,
asthma would you suggest removing the liquids, sprays, or plug-ins), hair sprays, deodor-
cat from the home when the allergy test is ants, soaps, shampoos, hand creams, after-shave
negative. If there is not cat and she wants to lotions, and body and hand lotions, to name a
test to “see if she is allergic,” point out that few—that contain perfume. Each or all of these
allergy takes time to develop and the test products can cause a problem for the person with
may be negative until she has been exposed asthma. Clothing often retains perfume odors
to the cat for some time. She may be posi- until washed or dry-cleaned. Too often, people
tive even if she has never lived with a cat as forget that clothing worn with perfume on a pre-
this allergen is very widespread. vious occasion will still retain the odor of the per-
fume and that odor, even though faint, may be
sufficient to act as a trigger for asthma. The smell VOCs are responsible for the nice “new” smell
associated with freshly dry-cleaned clothes can that is associated with new homes and new cars.
also be a problem. Paradoxically, the redecorating done in many
Odors, fumes, and aerosols from personal homes for the first baby may be harmful to the
products and cleaners used around the home can infant’s lung health.
cause problems for some individuals. Many The level of irritants within a home can be
cleaners are highly scented, and where this is a lowered by increasing air circulation, keeping
problem, three alternatives are available: bedroom doors open, using a ceiling fan, ventilat-
ing attics and crawl spaces, and using exhaust
1. Baking soda, which may be used as a regular, fans in the kitchen and bathroom.
all-purpose household cleaner and
deodorizer.
2. TSP (tri-sodium phosphate), sold in any hard- 5.5.11 Viral Infections
ware store, which can be used for heavy-duty
cleaning, shampooing carpets, and other gen- Of the known triggers of asthma, viral infections
eral-purpose cleaning. TSP is corrosive. are probably the most difficult to avoid. Persons
Hence, package instructions and cautions with asthma should avoid daycare centers and
should be read and followed. people who have colds and other respiratory
3. Substitute for TSP. For those concerned about infections. However, it is impossible to escape
phosphates, a phosphate-free cleaner is avail- infections totally. Handwashing as often as pos-
able at hardware stores. It is generally called sible will help reduce exposure to viruses, par-
“TSP Substitute” or “Liquid TSP Substitute.” ticularly if done immediately on returning home.
Having said that, there has been an enormous
Air purity in the home can be improved by reduction in community circulation of common
increasing circulation, ventilating attics and respiratory viruses associated with all of the
crawl spaces, lowering humidity, hanging dry- infection prevention strategies introduced for
cleaned clothes outdoors till the smell is gone, COVID-19.
and ensuring that clothes dryers and all exhaust Individuals with asthma should be encouraged
fans are vented to the outdoors. Air purity can to visit their local health unit each fall and be
also be contaminated by cleaning with disinfec- immunized against the influenza virus. Local
tants or bleach [116]. Limit the use of hydrogen policy will vary, but immunization is usually free
peroxide-based disinfectants. Use soap and water for them. They may have severe influenza that
instead of a disinfectant since that combination is will compromise their general health. The
known to kill the COVID-19 virus. If hydrogen Centers for Disease Control and Prevention
peroxide has to be used, then turn on the range (CDC) Guidelines thus recommends annual
hood, open a window, or turn on the central air influenza immunization for anyone with asthma.
system to reduce the level of pollutants in the air.
Indoor air is also contaminated by volatile
organic compounds (VOCs) from hydrocarbons, 5.5.12 Cold Air
formaldehyde, aromatics, terpenes, etc. VOCs
result in increased asthma symptoms and chest Merely going outdoors on a cold day can trigger
tightness. Increased air temperature within a an asthma attack in some individuals with asthma.
home results in increased levels of VOCs which For them, a washable scarf worn over the nose
are not affected by the ventilation rate or air and mouth will help trap and pre-warm the air
exchange rate [202]. Increasing the ventilation they breathe. This generally is sufficient to pre-
rates will not help reduce the levels of VOCs vent a cold-triggered asthma episode. They
which are released by furnishings, wallpapers, should be encouraged to exercise indoors and to
construction materials, fabrics, etc. [118]. In fact, minimize outdoor activity on cold days.
5.5.13 Exercise The best approach to the problem of exercise-

induced asthma is to control the asthma. Once it
Physical exercise is essential to the body’s well- is under control, individuals should pre-medicate
being. Avoidance is harmful. Individuals with with a bronchodilator (such as albuterol)
asthma should be encouraged to exercise even 10–20 min before exercising. If necessary, a
though the fear of an asthma attack due to exer- bronchodilator can be taken during the exercise
cise will inhibit them. All individuals with asthma period, but it will require 5 min to take effect. A
have symptoms with exercise. This section deals person who requires a bronchodilator more than
with those who have trouble with exercise once during the exercise or sports event (after a
because of the asthma or because of the type or pre-treatment) should be re-evaluated by a health-
intensity of the exercise. care provider. Frequent beta-agonist use is an
Individuals with exercise-induced asthma indicator of poor asthma control [207].
(EIA) experience bronchoconstriction during Having pre-treated with a bronchodilator, they
exercise, with the degree of obstruction being should perform a slow warm-up prior to the exer-
related to the individual’s bronchial hyperre- cise and a slow cool-down after [208]. A slow
sponsiveness (BHR). Normal pulmonary func- warm-up could consist of:
tion is restored anywhere from 15 to 30 min or
several hours after exercise [203]. Many indi- • 5–10 min of stretching, followed by
viduals can exercise through this refractory • 5–10 min of slow jogging, followed by
period. Others, rarely, may have a delayed-phase • A few 30-s sprints.
reaction anywhere from 6 to 8 h after exercise
[204]. The severity of bronchoconstriction The exercise session should last 30–40 min
depends on the intensity and duration of the [209]. To cool down, they should perform the
exercise [205]. warm-up in reverse. Start with sprints, follow this
Exercise symptoms will abate when the with slow jogging, and end with slow stretching.
asthma is controlled. Only a few with otherwise If necessary, a bronchodilator can be used during
well-controlled asthma will have symptoms with exercise.
exercise. Exercise symptoms in this situation are Non-pharmacological approaches to exercise
more likely with very strenuous exercise, exer- include covering the nose and mouth with a scarf
cise without a warm-up period, exercise in very in cold weather, wearing a nose and mouth mask
cold air, or exercise in the presence of a coexis- with a carbon filter during pollen season, exercis-
tent trigger, such as an aeroallergen or a viral ing in warm and humid air such as that found
infection. For these persons, special measures are around an indoor swimming pool [205], and
needed. Most will obtain protection with an breathing slowly through the nose. Exercising in
inhaled beta-agonist taken immediately before a warm humid environment will reduce the level
exercise. The same medication will also provide of bronchoconstriction [209]. This may explain
relief. General measures that are helpful include: why swimming is the form of exercise least likely
to trigger exercise-induced symptoms.
• Pre-medication if required, 10–20 min before Children should be encouraged to be active
exercise. and to live as normal a life as possible. A seden-
• Improvement of general fitness levels. tary lifestyle will result in poor levels of physical
• A slow warm-up and cool-down period before fitness which is detrimental to their well-being
and after the exercise session [206]. [210]. Regular exercise increases fitness,
• Avoidance of exercise in dusty places, in cold improves tolerance to exacerbations, and aids
air, on windy days, and on times of high pol- both social and psychological development. It
len counts, thermal inversions, and high levels also prevents obesity, something that may
of air pollution. increase the severity of asthma.
Exercise-induced asthma (EIA) can lead to an The IOC also permits the use of theophylline
aversion or dislike of exercise. For this reason, it and ipratropium bromide [205, 206]. Inhaled cor-
is important for the asthma to be brought under ticosteroids are permitted. The athlete should
control so that the fear of exercising is reduced or always obtain up-to-date information from the
eliminated. athletic associations and the team healthcare pro-
vider on what is and is not permitted.
5.5.13.1 Asthma and the Athlete Athletes with asthma may have other allergic
An overview of this important topic is given disorders such as allergic rhinitis. Before using
here. More details are to be found in Sect. an OTC preparation for these conditions, consul-
8.10—“Competitive Athletes.” The good news is tation is essential.
that many Olympic athletes have asthma and
this has not prevented them from competing
[211]. Famous athletes who have asthma include 5.5.14 Latex
soccer star David Beckham; Jackie Joyner-
Kersee winner of 6 Olympic medals; Greg The only way to avoid latex allergy is through
Louganis winner of 5 Olympic medals for div- avoidance of all latex products. This requires that
ing and 47 national titles; marathon runner and the sensitive individual be aware of all possible
Olympic gold medalist Paula Radcliffe; NFL sources and use only non-latex products. It will
football player and Super Bowl champion also be necessary to avoid all forms of latex con-
Jerome Bettis; basketball star and winner of 5 tamination, including avoidance of foods pre-
NBA championships Dennis Rodman; and pared by handlers wearing latex gloves [79, 215].
Olympic gold medalist and ice-skater Kristi
Yamaguchi, to name just a few. Among Olympic
athletes, asthma is the most common chronic 5.5.15 Conclusion
condition. An Australian study found that 8% of
Olympic athletes have asthma [212]. Environmental changes are often suggested by
Proportionately, more Olympic athletes with healthcare professionals—reduction of exposure
asthma have won Olympic medals than non- to even a single indoor allergen such as HDM
asthmatic athletes [213]. will reduce morbidity even while their exposure
Athletes with asthma should remain under the to other allergens remains unchanged [216]. That
supervision of a healthcare provider, have their being said, single-component intervention for
asthma under control, and avoid their triggers. allergies is no longer recommended [163]. For
Athletes involved in competition must know instance, installing dust mite covers alone on a
which medications are banned by the different mattress will not eliminate the dust mite problem
sporting committees. Among the aerosolized if the room is filled with clutter and stuffed furni-
beta-agonists available in the USA, only terbuta- ture. A multi-faceted approach needs to be taken,
line sulfate and albuterol are permitted by the whereby all other sources of dust mite in the
International Olympic Committee (IOC). Other room are identified and removed or corrected.
beta-agonists, including OTC medications, are This can be much more expensive than just
banned. Good control of asthma is important as installing dust mite covers.
the tremor caused by beta-2 medications may However, implementing these environmental
interfere with athletic ability in some sports. changes has often proven difficult, if not impos-
The World Anti-Doping Agency has banned sible, for most people with asthma. The health-
all beta-agonists except specific doses of inhaled care provider must remember that people with
salbutamol, formoterol, and salmeterol. A recent allergies will not go to extraordinary lengths to
study showed that oral beta-agonists can improve minimize allergen exposure, nor should they be
anaerobic performance, increasing sprint and expected to do so. It is essential to keep in mind
strength in healthy individuals [214]. that all the changes will have costs, in terms of
time, energy, and money. Simple suggestions that can be especially useful in determining the causes
do not require drastic changes to their lifestyle of both immediate and delayed allergic reactions.
are more apt to be followed than complex pro- Diaries that are carefully maintained for a period
grams, while suggestions that are expensive and of time can show important patterns that would
time-consuming will not be welcomed. otherwise be easily missed. They must be encour-
Simple measures are best. These are easy to aged to be detectives, to find their triggers, and to
remember and therefore can be consistently per- be made aware that it is the cumulative effect of
formed. The asthma educator should be a collab- exposure to many and/or repeated triggers, rather
orator and be ready to help the person with than just one trigger, that precipitates an asthma
asthma to make the needed changes part of a exacerbation.
daily routine. Changes should preferably be Biological changes such as menses and preg-
implemented one at a time, rather than all at once. nancy also affect asthma as noted in more detail
All suggested changes should, of course, take in Chap. 4. Hormonal changes can affect the state
into consideration the socioeconomic status and of asthma in women. About 40% of women with
the financial resources within the family. Changes asthma will have perimenstrual exacerbations
require both time and effort: they will not take [217]. The highest probability of an exacerbation
place overnight. The person with asthma should occurs on the first day of menstrual flow and
be in control. Actions that are chosen by them are drops thereafter; conversely, the lowest preva-
more likely to be effective. lence tends to be in mid-cycle, between days 17
The changes that the asthma educator sug- and 19, after which it rises until the premenstrual
gests should be in proportion to the severity of phase [218]. Menses by itself does not increase
the asthma. The educator will have little credibil- diurnal variability in PEF [219], but for women
ity if avoidance of most potential triggers is rou- who have asthma, there is a significant correla-
tinely suggested with every patient. tion between the increase in asthma symptoms
(20%) and premenstrual symptoms. Women with
asthma who had the most severe dysmenorrhea
5.6 Identification of Triggers (difficulty and painful menstruation) also had the
greatest decrease in pulmonary function during
Individuals with asthma often have difficulty menstruation [220].
describing their triggers, and careful questioning During pregnancy, one third of women with
is required in order to elicit them. It is helpful asthma will find that their asthma has worsened;
when identifying triggers to consider the follow- one third will report no change; and one third will
ing factors: actually report an improvement. This is further
discussed in Chap. 8.
• Time of day.
• Time of year.
• Location. 5.7 Home Assessment
• Activities.
• Emotions. Conducting a home assessment [221] of aller-
• Food. gens requires the cooperation of the family. A
• Weather. visit to the home is an ideal way to identify trig-
• Viral infections. gers and to assess the amount of allergen expo-
• Biological changes. sure that the person with asthma faces while
indoors. It is important to let them know that the
A daily diary maintained for a few weeks (ide- home is not being checked for cleanliness but,
ally, for a few months) can be extremely helpful rather, that an attempt is being made to identify
in identifying triggers or combinations of triggers allergens and irritants and to determine how they
that affect the individual with asthma. The diary can be avoided. It is disappointing how often
there is a smell of tobacco in a home when the they have a vested interest in maintaining the
educator has been told there is no smoking in the home.
home. When performing a home assessment, four
Here are some questions whose answers make specific areas must be inspected.
a good starting point in a home assessment.
Bedroom Furniture, mattress, pillows, bedding,
• Is the home owned or rented? carpet, closet, stuffed toys, carpet/floor covering.
• Where is it located?
• Is it a single-family home or a multi-family Living Room Furniture, carpet/floor covering.
structure?
• Is it a permanent structure or a mobile home or Basement Heating/cooling system, type of heat-
trailer? ing fuel used, wet or damp areas.
• How old is it?
• What type of heating or air-conditioning sys- Kitchen Odors; presence of cockroaches, rats,
tem does it use? or mice; food storage; garbage disposal method
• Is the heating or air-conditioning system in (cans with tight fitting lids?); frequency of gar-
good condition? How often is it serviced? If it bage disposal (how often done?); type of cooker;
has filters, how often are they changed? When exhaust fan vented to the outdoors? Check to see
were they last changed? if there is an exhaust fan in the bathroom too.
• Is a humidifier or dehumidifier in use? How
often is it cleaned? When was it last cleaned? Dampness is important since it is a significant
• Are there any smokers in the home? At the risk factor for BHR and respiratory symptoms
daycare? Do relatives or grandparents smoke? [222, 223]. It has also been associated with
• If there a fireplace in the home, how often is it increased night-time symptoms.
used? How often is it cleaned? When was it High indoor humidity increases the level of
last cleaned? dust mite allergen (dust mites prefer high humid-
• Are there pets in the home? What kind are ity) and lowers the air exchange indoors which
they? leads to increased inhalation of aeroallergens and
• What floor coverings (carpets, linoleum, hard- irritants [223]. A hygrometer can be used to mea-
wood, other flooring) are in use? In which sure indoor humidity. A dehumidifier can help
rooms? lower the humidity.
• What is the normal indoor temperature and The use of bottled gas, paraffin, and other
humidity? unusual heating fuels is associated with increased
wheezing [224]. Kerosene, gas heaters, and ovens
As regards the first question, whether the release carbon monoxide, nitrogen dioxide,
home is owned or rented, environmental con- polyaromatic hydrocarbons, and sulfur dioxide
cerns can be difficult to resolve in a rented home. as by-products of combustion [225]. These can
Major problems such as dampness and mold will affect respiratory function.
require the involvement of the owner, who may The use of gas stoves as a heat source is a hall-
be not only reluctant but also adamantly opposed mark of urban poverty. When stoves are used to
to take any action that involves expenditure of heat a house, irritants spread through the living
money. Dealing with landlords can be very diffi- area. The irritants, a by-product of combustion,
cult. In an apartment building, for example, it are easily respirable. A study found that gas
does not make much sense to eradicate cock- cooking was associated with asthma symptoms
roaches from just one apartment, because re- and with exacerbations, and in a comparison with
infestation will occur from the other apartments. women who did not use gas for cooking, women
People are more willing to take care of problems who cooked with gas had reduced FEV1 and
in their own homes. This is understandable since increased airway obstruction [226–228].
It is also important to determine if the family • Skin changes (premature aging).

has access to washing machines and dryers and • Effects on the fetus and child.
owns (or can borrow) a vacuum cleaner and the
type of vacuum cleaner in use. ETS has a detrimental effect on health. It
After the allergens have been identified, then [230–232]:
eradication or minimization measures can be dis-
cussed with the family. They must be educated • Reduces lung function in utero.
about the dangers and health risks to the person • Permanently impairs lung growth and func-
with asthma. This will likely take more than one tion in children and adolescents.
visit and can be reinforced through pamphlets, • Accelerates the age-related decline in lung
telephone calls, and subsequent clinic visits. But function in adults.
the home visit is an important beginning. It will • Increases the severity of symptoms of asthma.
provide the asthma educator with indicators as to • Increases the risk of lower respiratory tract
the willingness of the individual and their family infections.
to consider recommendations. • Has a dose-dependent relationship with death
The CDC provides a comprehensive check- from lung cancer, emphysema and COPD,
list for “Home Characteristics and Asthma heart disease, stroke, and circulatory and
Triggers.” It is detailed and can be found at respiratory diseases in both males and females.
https://www.cdc.gov/asthma/pdfs/home_
assess_checklist_P.pdf. COPD can be confused with or can coexist
with asthma. (See Chap. 4.) Even without overt
COPD, smoking affects lung health. Airway
5.7.1 Smoking reactivity is increased by environmental tobacco
smoke and shown in decreased peak flows [111],
For additional information on this topic, see Sect. while wheezing has been linked to both active
8.9—“Smoking.” and passive smoking [224]. Cigarette smokers
Smoking is unhealthy. Not only is this general exhibit reduced lung function when compared to
knowledge, but the specifics of the dangers are non-smokers [195]. The good news is that smok-
well known. In 2018, in the USA, the number of ing cessation for a period as short as 6 months
cigarette smokers declined to 14% of adults from results in increased FEF25–75 [233].
the 15.5% of 2016, down from 20.9% in 2005 Persons with asthma should not smoke,
[229]. That is the only good news. either actively or passively. In adults with
While the risks are higher for tobacco smokers asthma, exposure to ETS for over 1 hour results
than for those exposed to the smoke of others (the in a reduction of FEV1 and FVC of about 20%.
so-called second-hand smoke), the risks to the ETS affects the severity of asthma, reduces
latter (“passive smokers”) are not negligible. quality of life and physical health status, and
They are exposed to all the poisons of environ- increases the use of healthcare services.
mental tobacco smoke (ETS). ETS contains irri- Children have little control over their environ-
tants such as formaldehyde, sulfur dioxide, and ment. An example of objective changes is the
ammonia. Although the specifics of ETS effects increase in peak flow variations in children who
are well known, they are worth reiterating. They live in a house with a smoker. Exposure to
include: tobacco smoke in the home results in increased
asthma symptoms, more frequent exacerba-
• Emphysema and COPD. tions, increased use of medication, more admis-
• Lung cancer. sion to hospitals, and more life-threatening
• Heart disease and stroke. asthma episodes [234]. Exposure is also corre-
• Peripheral vascular disease. lated significantly to deficits in FEV1 as well as
• Bladder cancer. PEF that are long-lasting [235].
Exposure to tobacco smoke has been shown ex-smokers, PEFR increased, but there was no
to turn on or off 370 different genes in the air- difference in asthma control or FEV1 [243].
way epithelium [236]. Tobacco smoke para- Current smokers should always be asked if
lyzes the cilia. Of greatest concern are the they are ready to quit. Identifying smoking cessa-
transgenerational effects of smoking. Both tion programs is a start, but insufficient by itself.
maternal and grand-maternal smoking have Attention to the social determinants of health in
been associated with asthma in childhood [237, smokers is important [244]. Smoking is related to
238]. Research has also shown that both sec- socioeconomic status, and resources may not be
ond-hand and third-hand exposures to tobacco suitable for those already economically disad-
during fetal development have long-lasting vantaged. Nevertheless, the individual smoker
effects on lung development and morbidity should be helped by the educator to quit smok-
[239]. Fathers have not been left out of the ing. At the same time, the discerning educator
research. Exposure to tobacco smoke through will realize the individual can only be helped if
the paternal line was associated with the child there are wider attempts to address healthy
being overweight or obese, particularly for inequalities.
boys at age 5 [240].
Smoking during pregnancy is dangerous.
Spontaneous abortion is more likely. A well-rec- 5.7.2 Vaping
ognized causal relation exists between smoking
during pregnancy and sudden infant death syn- The number of those who access tobacco by vap-
drome (SIDS). There are long-term effects. ing, using electronic cigarettes (EC), has
Infants are more likely to be of low birth weight, increased dramatically; at the same time, the
and this effect on size is still seen at 3 years [241]. number of those who access tobacco by smoking
The immediate consequences of low birth weight has declined. High school and college students
include a higher chance of needing intensive care are the fastest-growing demographics [245].
and subsequent risk of chronic lung disease of Vaping, so-called because it consists of inhal-
prematurity. Maternal cigarette smoking can alter ing the vapor emitted by a device, usually
or modify the immune function of the fetus [242]. involves a variety of electronic vapor-producing
Therefore, it is not surprising that the risk of products including e-cigarettes (EC), e-cigars,
respiratory problems in infancy and childhood is e-pipes, e-hookahs, hookah pens, vape pens,
further increased with exposure to smoke after and vaping pipes [246]. Vaping is the fashion-
childbirth [163, 234, 235]. able new way to smoke without actually placing
Exposure to ETS in utero is a specific risk fac- a conventional tobacco cigarette between one’s
tor for asthma in addition to the general conse- lips and is targeted through design, flavors, and
quences mentioned earlier. Exposure to ETS after marketing toward young people. Currently there
birth further increases the risk of asthma in chil- are more than 7500 different flavors of EC with
dren [164, 223, 224]. Many of the consequences menthol, sweet, and fruity flavors the most pop-
are both time- and dose-related. In other words, it ular [247]. In a recent study, 63% of 4073 who
is never too late to reduce or stop smoking. used an electronic vaping product also used
Smoking also reduces the efficacy of asthma marijuana [248]. A disappointing finding was
medications such as oral (OCS) and inhaled that subjects with asthma were more likely than
(ICS) corticosteroids. A study done by Chaudhuri controls to report current cigarette smoking,
and colleagues checked FEV1, PEFR, and asthma marijuana use, and use of an electronic vaping
control in non-smokers, current smokers, and ex- device.
smokers. After taking the prescribed asthma OCS EC contain nicotine concentrate, flavorings,
or ICS, they noted that all three parameters additives, propylene glycol, glycerol, and some-
improved in non-smokers. None of the three times an assortment of other chemicals. EC
parameters improved with current smokers. With products do not either identify or list the levels
5.8 Application 163
of specific flavoring chemicals that are contained ing an increase in the inflammatory markers,
within individual products. While high doses of reduced peak flow, and FEV1/FVC ratio and
some flavor chemicals may be safe for ingestion, increased FeNO and exhaled breath condensate
they may become toxic when inhaled. Vaping pH [254].
occurs at high temperature. When vaped, the fla- It is clear that inhalation of smoke of any
vor chemicals degrade into toxic products such kind—directly or indirectly—damages the deli-
as aldehydes (including formaldehyde and benz- cate structure of the lining of the airways and has
aldehydes) and vanillin, which irritate the respi- a serious effect on lung function. This also applies
ratory tract. Formaldehyde is a known to inhalation of cannabis which can also trigger
carcinogen. an asthma exacerbation [83].
Some of the reported side effects likely due to It should be noted that people with asthma
one of the many ingredients in EC include: who are exposed within their homes to the par-
ticular allergens to which they have been sensi-
• Eye, mouth, and throat irritation. tized are likely to have a more severe form of the
• Dizziness. disease [255].
• Headache.
• Cough.
• Nausea. 5.8 Application
• Trouble breathing.
• Nosebleeds. 1. Look around your home. Imagine that you
• Chest pain. have asthma, and list all the possible triggers
• Heart palpitations. to be found in and around your home. Then
• Allergic reactions. write down what you would do to eliminate or
reduce exposure to those triggers. A sample
Lung immune response is altered by EC chart is shown below.
usage, impairing innate immunity, altering bacte- 2. Determine the type of pollens that proliferate
rial defenses, and causing oxidative stress and in your area. Construct your own pollen chart
inflammatory responses [249–251]. EC use can listing the periods of pollination for trees,
damage the lungs. Known as e-cigarette or vap- grasses, and weeds.
ing use-associated lung injury (EVALI), respira- 3. In Chap. 17, do case study numbers 1 and 2
tory symptoms include cough, shortness of (Table 5.5).
breath, or chest pain. There may be gastrointesti-
nal symptoms of nausea, vomiting, diarrhea, or
stomach pain. Other symptoms may include Table 5.5 Home assessment
fever, chills, or weight loss [229]. Symptoms can
Source Trigger Reduce exposure by …
develop over a few days or even weeks.
Kitchen
EC contain various levels of nicotine and may Living room
also be used with tetrahydrocannabinol (THC). Family room
Vitamin E acetate has been found in the lung of Bath/washroom
those who have EVALI [252]. Vapers who Bedroom 1
smoked EC that contained vitamin E acetate had Bedroom 2
serious EVALI that required hospitalization and Bedroom 3
Basement/cellar
sometimes resulted in death [253].
Garage
A study comparing 25 people with asthma Yard
with 25 healthy individuals without asthma found House pets
that after using just 1 e-cigarette, there were House plants
decided changes in both pulmonary function in Heating/cooling
the moderate, stable asthmatic individuals includ- system
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Medications Used in Asthma
Management
6
Contents
6.2 Principles of Medication Use 178
6.3 Available Medications: Broad Categories of Use 179
6.4 Q
uick-Relief Medications (“Rescue Medications”) 180
6.4.1 Short-Acting Beta-Agonist (SABA) Bronchodilators 180
6.4.2 Short-Acting Anti-cholinergic Bronchodilators 181
6.4.3 Systemic Corticosteroids 181
6.4.3.1 Side Effects of Systemic Corticosteroids: Some Comments 182
6.4.3.2 Use of Systemic Corticosteroids in Severe Acute Asthma 183
6.5 L
ong-Term Asthma Control Medications 183
6.5.1 Inhaled Corticosteroids (ICS) 183
6.5.2 Long-Acting Beta-Agonists (LABA) 185
6.5.3 Long-Acting Muscarinic Antagonists (LAMA) 185
6.5.4 Combination Products 186
6.5.5 Leukotriene Receptor Antagonists (LTRA) 186
6.5.6 Immunomodulators and “Precision Health” 188
6.5.7 Long-Term Systemic Corticosteroids 193
6.5.8 Theophylline 194
6.5.9 Cromolyn and Nedocromil 196
6.6 Other Medications Used in Asthma 197
6.7 Immunotherapy in Asthma (“Allergy Shots”) 197
6.8 L
ow Evidence-Based Medications as Treatment Options 206
6.8.1 Approach to the Use of These Medications 206
6.9 Role of Bronchial Thermoplasty in Treatment 206
6.10 Concern About Side Effects: General Approach 207
6.11 Classification of Severity After Treatment 209
6.12 Step Approach to Asthma Management 211
6.13 Goals of Therapy 214
6.14 Quality-of-Life Scores 215
176 6 Medications Used in Asthma Management
6.15 Conclusion 217

References 217
Key Points • Those with asthma should always be

• Asthma medications are available in dif- partners with the educator in:
ferent therapeutic groups: –– Developing goals of care
–– They can be broadly described as for –– Completing quality-of-life scores
immediate relief or long-term prophy- –– Planning the details of therapy and
laxis, although there is some overlap. its adjustment
–– Specific medications and specific
dosages are required with different
degrees of severity.
–– Medication type and dose must be Chapter Objectives
adjusted according to clinical After reading this chapter, you should be
condition. able to:
–– Use of a step-wise approach is
helpful. • Describe the different medications used
• Asthma medications are generally safe, in the treatment of asthma and their ben-
but there are specific potential side efits and drawbacks, including potential
effects requiring monitoring. side effects
• Some older medications (theophylline, • Understand the importance of initial and
nedocromil, and cromolyn)—now no regular reassessment of severity in
longer in common use and often diffi- determining type and dose of medica-
cult to obtain—are listed although tion use
asthma can be well managed with many • Develop goals of care jointly with the
newer medications. person with asthma (or their caregiver)
• Medications not specifically studied for and understand their relationship to a
asthma—such as troleandomycin and step approach to asthma treatment
gold—used in the past as corticosteroid- • Understand the importance of quality-
sparing agents, are included. They may of-life scores and be able to incorporate
be used by only very few of those with them into all assessments
asthma, and strategies are suggested for
replacing them with proven
medications.
• Newer medications (biologics) are an 6.1 Introduction
extremely important addition for those
with more severe asthma. Successful asthma self-management involves:
–– These medications have led to reeval-
uation of the underlying nature of • Medications for the prevention and treatment
asthma. of symptoms, along with
• Good environmental control
To be effective, asthma medications must be was rarely explicitly stated, it was implied that
carefully chosen. So too must be their dosage and minimal treatment should be used first, followed
route of administration. Many effective medica- by an increase in medication dosage, or substitu-
tions are currently available, and most can be deliv- tion of more potent medications, if the initial
ered to the lungs through different (and effective) approach proved unsuccessful or only partly suc-
delivery devices. As a general rule, the medications cessful, and then accepting full asthma control as a
in common use have few significant side effects. legitimate objective, by a multi-pronged approach
Thus, the medications are safe for most people with that included high doses of potent medications.
asthma, though troublesome side effects can some- The logic behind this is fallacious: the false
time occur even when they are used appropriately. assumption is that there is a progression from non-
And, as with other medications, significant side existing asthma, through mild to very severe, in
effects may be experienced when other medical people with asthma. In reality, most individuals
conditions exist in addition to asthma or when are remarkably consistent over time, within limits,
users are also taking other medications or herbal in terms of disease severity. Hence, in most cases,
remedies. Detailed advice on the individual’s cur- it is probably better to first achieve control and
rent health situation should always be sought from then reduce treatment, rather than vice versa.
a physician or healthcare provider.
In any treatment plan, disease severity is an
important consideration. The intensity of the effort
to control asthma should depend on the severity of Points to Ponder
the disease. Severity should also be re-estimated at Principles of Treatment
each contact. Overall (“long-term”) severity is also
important, although there is no easy method to • Recognition of the chronic nature of
determine this. Nevertheless, both background asthma
history and current history can be used to obtain a • Recognition that deterioration can be
preliminary determination. Some items that can be prevented
used to assess severity over time are: • Dose and delivery systems must be
individualized
• The age of onset
• Frequency of admission to hospital
• Any ICU admission Once an assessment of severity has been com-
pleted, the intensity of treatment can be deter-
Features in the current history that are helpful mined. “Intensity” here refers to the type, dose,
in estimating severity at a specific point in time and strength of drug therapy to be used and also
include: to the rigor with which asthma triggers are to be
avoided [1]. For example, the recent guideline
• Daytime symptoms/limitation of activity update [2] lists six treatment steps; for a person
• Night-time symptoms (nocturnal asthma) with moderately severe symptoms, treatment
• FEV1 or PEF should start at Step 3. In such a situation, starting
• Variability in airflow obstruction (FEV1 or at Step 1 would lead to unnecessary prolongation
PEF) of symptoms and erode confidence in the health-
care provider.
Refer to Chapter 4 for a more detailed discus- Conversely, if treatment intensity is tracked over
sion on assessing severity. a longer period, it can be used to estimate severity.
An assessment of severity is a good guide to For example, the amount of relieving treatment
the intensity of treatment that needs to be offered. (bronchodilator) used on a daily basis will indicate
Step-wise management has been part of the the frequency of symptoms. This is often a good
approach to asthma for many years. Although it guide to a need for change in treatment.
Severity must also be gauged through objec- regular medication required to control persistent
tive measurements. These have been discussed asthma. Deterioration can be predicted by using a
earlier and include both variability in daily peak peak flow meter to monitor lung function, follow-
flow readings and formal pulmonary function ing a symptom score sheet, and keeping a record
testing. While the “intensity of treatment” of the frequency of bronchodilator use. This
approach is used here, an alternative is the “step- allows early deterioration to be identified, and
wise” approach. However, the resulting treatment action taken that, hopefully, will prevent further
is not likely to be very different when either of progress of the exacerbation.
the two approaches is used. A more complete
description of severity is similar to the concept 3. Recognition that doses and delivery systems
that asthma does show a continuum. must be tailored for each person with asthma
While it is generally true that inhaled cortico-
steroids and bronchodilators are required for
6.2 Principles of Medication Use most individuals with asthma, the optimum dose
will vary considerably from one person to
The following principles underlie any program of another. Time should be taken to determine and
successful treatment: adjust the dose.
There are many ways of delivering medication
1. Recognition that asthma is a chronic disease, to the respiratory tract, and those methods are
with acute exacerbations described in detail in Chap. 7. A detailed knowl-
This is very important. In the past, asthma was edge of the various medication devices, together
often considered only as an acute disease. Thus, with individual preferences, is necessary to deter-
both the person who had asthma and the health- mine the final selection of a delivery system. This
care provider felt comfortable in assuming, when brief overview has the limited objective of intro-
recovery seemed to occur after acute asthma, that ducing the topic and making some of the com-
the problem had been resolved. Environmental ments on medications understandable.
exposures that may have led to deterioration were The three major types of delivery system are:
neither identified nor avoided rigorously, and the
long-term approach of using prophylactic drug • Metered dose inhalers (MDIs)
therapy was not emphasized. • Dry powder inhalers (DPIs)
Once asthma is accepted as a chronic disease, • Nebulizers
then other factors—such as environment, the role of
long-term treatment, and other issues including per-
sonality, coping styles, and family relationships— MDIs
can be addressed in detail. Persons with asthma, and The metered dose inhaler (MDI) is probably the
their families, need to understand the disease fully single most effective way of delivering the drug; if
and must have a written plan for dealing with exac- a spacer or holding chamber is used, the device’s
erbations and episodes of deterioration. efficiency and effectiveness is further improved.
Not all medications are available in this prepara-
2. Recognition that deterioration in asthma can tion. Current MDIs contain “carrier” substances
often be prevented or predicted and a propellant to allow the drug itself to be
If the concept of preventable and predictable expelled in droplet form. Nowadays, hydrofluoro-
deterioration is accepted by persons with asthma, alkane (HFA) is the most likely propellant.
then a proactive approach can be recommended
and implemented. They should identify their trig- DPIs
gers and attempt to avoid them. If they do this Many dry powder devices are available. Examples
conscientiously, they may reduce the amount of include the Turbuhaler, Diskus, Ellipta, and
medication, especially “rescue” medication, that Aerolizer, each of which varies in its ability to
is needed, but avoidance will not eliminate the successfully deliver medication to the lungs.
6.3 Available Medications: Broad Categories of Use 179
Under some situations, DPIs are as effective as, The current wide range of other potent
or more effective than, MDIs. They generally medications, often used in combination, has
contain lactose, and they vary in the degree of meant better quality of life in those with
systemic absorption of the medications. asthma, without possible side effects from
corticosteroids. The use of the medications
Nebulizers listed in Sect. 6.8 (“Low Evidence-Based
Nebulizers are a popular delivery system but Medications as Treatment Options”) was
inefficient in terms of dosages delivered. The explored in the past, in entirely laudable
large doses used lead to a perception, among attempts to avoid systemic corticosteroids.
individuals with asthma, that they are highly They are probably not needed now, but are
effective. It is unlikely that nebulizers are required included as some people may have found them
for any more than a minority of individuals, even useful and wish to continue rather than change
in infancy and childhood. to a newer medication. Lastly, precautions in
Medications for nebulizers come in a variety the use of theophylline are given in detail.
of preparations—some contain preservatives that Theophylline was once the mainstay of long-
may cause some irritation to the airway; others term asthma management in the USA, the last
require dilution with saline to give an appropriate western country to realize the value of inhaled
volume; or, they may be available in ready-to-use corticosteroids and beta-2 agonists. People
nebules. with asthma today can be symptom-free by
Individuals with asthma should participate in choosing from a wide range of safe and effec-
the selection of the delivery system with the edu- tive medications. Theophylline is not needed
cator and the healthcare provider. If they feel they in asthma, but a few devotees remain, and
have had a say in the choice of delivery system, asthma educators must still be knowledgeable
they will be much more likely to take the medica- about this group of medications.
tion as scheduled. They should also have the
physical dexterity and strength to be able to use
the chosen device. 6.3 Available Medications:
On each occasion that a healthcare provider or Broad Categories of Use
an educator sees someone with asthma, device
technique and the use of the drug should be The standard asthma arsenal consists of medica-
reviewed. Studies indicate that deterioration in tions in the following categories [1–5]:
usage technique occurs within 3 weeks of the initial
teaching. Hence, constant review of technique is 1 . Quick-relief medications (“rescue
essential for continued successful use of the device. medications”)
The medications are arranged in broad catego- • Bronchodilators—short-acting beta-
ries. The order in which they are listed corre- agonists
sponds, roughly, to their utility. Note that the • Bronchodilators—anti-cholinergic
length of individual descriptions and discussions • Systemic corticosteroids
is most assuredly not a reflection of the value of 2. Long-term asthma control medications
the medication to someone who has asthma. • Inhaled corticosteroids
Systemic corticosteroids are dealt with in detail, • B r o n c h o d i l a t o r s — l o n g - a c t i n g
as this is a group in which side effects do occur. beta-agonists
In the past, they were needed often in the treat- • Combination products
ment of asthma. Now they remain essential in • Leukotriene inhibitors
severe acute asthma and are given over a few • Systemic corticosteroids
days only. Their long-term use in severe chronic • Long-acting anti-cholinergic (muscarinic)
asthma is required much less frequently these agents
days. • Theophylline
3. Immunomodulators/biologics increasing airway reactivity [7]. These medica-

4. Other innovative and quasi-experimental
tions should be used only for short-term relief.
therapies For example, a recent study of 145 persons with
Each group is briefly reviewed here. asthma who were allergic to house dust mite
observed and confirmed a small decline in FEV1
in those on short-acting, but not in those on long-
6.4 Quick-Relief Medications acting, beta-2 agonists [8]. When asthma is under
(“Rescue Medications”) good control, inhaled beta-2 agonists are only
infrequently required, on an as-needed (prn)
These are bronchodilators used to relieve symp- basis. This should be twice a week or less; more
toms or to obtain rapid improvement in severe frequent use should lead to re-evaluation of the
acute asthma where systemic corticosteroids are severity of the asthma. Some educators and pre-
used. Systemic corticosteroids are not usually scribers may include pre-treatment for exercise-
mentioned in the context of quick relief, but their induced asthma more than twice/week as a reason
placement here is appropriate. However, while for re-evaluation, while others may not.
bronchodilators are almost always required to Beta-agonists may be given orally or by inha-
provide relief, systemic corticosteroids, with lation. Oral administration is rare in asthma
their major potential side effects, are reserved for because it causes an increase in side effects; for
the most severe exacerbations. this reason, the inhalation preparations [nebuliz-
This section really deals with symptomatic ers, metered dose inhalers (MDI), and dry pow-
treatment, of which the most widely used are der inhalers (DPI)] are all more widely used.
beta-2 agonists (bronchodilators). Any of the Onset of action occurs within a few minutes, with
available medications may be employed, and a peak within 30 minutes and a total duration of 2
their main use is to abort episodes of asthma or as to 4 hours. Side effects can include a slight
a preventive treatment before exercise. As men- increase in heart rate and mild muscle tremor.
tioned earlier, the frequency of inhaled broncho- Tolerance, a decrease in bronchodilator effect,
dilator use is a good guide to asthma severity. and shortened duration of action when the drugs
are used on a regular basis are intrinsic parts of
beta-2 agonist use. This is a sharp reminder of one
6.4.1 Short-Acting Beta-Agonist of the reasons why SABA medicines should not
(SABA) Bronchodilators be used on a regular basis. Tolerance also applies
to side effects of SABA such as tremor. While the
Short-acting beta-2 agonists (SABA) act as bron- absence of tremor may be welcome, if someone
chodilators directly on the smooth muscle of the with asthma has no side effects when being tested
airway and provide immediate relief. The most for reversibility, then the educator must explore
widely used relievers are albuterol and terbuta- the possibility of regular SABA use.
line. They act on the beta-receptors. Beta-1 It is worth noting that resistance (i.e., loss of
response occurs on the cardiovascular system and effectiveness) to the beta-agonists:
beta-2 response on the smooth muscle. SABAs
are generally safe. Obvious side effects include • Is different
skeletal muscle tremor, tachycardia and palpita- • Occurs late in an asthma episode
tions, and central nervous system (CNS) stimula- • Is ominous
tion (especially hyperactivity) [6], but these are • Demands a high dose of systemic corticoste-
short-lived. roids urgently
Of more importance is the long-term regular
use of these medications. There has been some Thus, most healthcare providers would sug-
concern in the past that regular long-term use of gest that their regular use be limited to two or
beta-2 agonists might increase asthma severity by three times per week. However, as noted, more
6.4 Quick-Relief Medications (“Rescue Medications”) 181
frequent use is permitted (as in the prevention of both the number of circulating eosinophils and
exercise-induced asthma) and may be essential mucosal mast cells. They also appear to decrease
during acute exacerbations. mucus secretion and appear also to restore dis-
While the side effects of beta-agonists, such as rupted epithelium.
tremor and tachycardia, may be transient, they Corticosteroids should not be confused with
can cause great distress in some individuals. the androgenic steroids often used illegally by
Hence, if they cause unpleasant side effects to athletes to increase muscle bulk. This dangerous
occur when used to prevent exercise-induced use of one type of steroid, with its attendant neg-
asthma, ipratropium (Atrovent™) is an appropri- ative publicity, has caused much confusion, and
ate bronchodilator choice. many patients tend to be wary of any medica-
tions with similar-sounding names. They will
have to be reassured on this point, and it will
6.4.2 Short-Acting Anti-cholinergic generally be helpful to be proactive and to
Bronchodilators explain that the steroids used in asthma are glu-
cocorticoids and not androgenic or anabolic ste-
Anti-cholinergic medications are much less com- roids. (Glucocorticoids are similar to the natural
monly employed in asthma than in other lung dis- hormone cortisone produced by the adrenal
orders, such as COPD. Ipratropium (Atrovent) is gland, while the androgenic steroids are similar
the only short-acting medication that acts on the to natural male sex hormones.) It might also help
cholinergic receptors. When given by inhalation, to remind them that estrogens—the female sex
it starts working within 30 minutes and is there- hormone in birth control pills—are also
fore used as an adjunct to beta-2 agonists in the steroids.
emergency department (ED) and in-patient set- It is of interest, and of importance, that after
tings, particularly with children. Its effect lasts many years of use there is no evidence that the
from 3 to 6 hours. This medication is particularly basement membrane of the airways is thinned by
effective in children and elderly people. If deliv- corticosteroids.
ered through a nebulizer, eye protection should Adrenal hormones are controlled in a manner
be worn to prevent dilation of the pupils, eye irri- similar to that of a servo loop. This is an engi-
tation, and the possible development of neering phrase and best understood by
glaucoma. considering a domestic room heater whose ther-
While SABAs help the respiratory muscles to mostat is set at a particular temperature level.
relax, the anti-cholinergic bronchodilators work When the temperature falls below the set level,
to prevent the muscles from tightening. Thus, the thermostat causes the heater to switch on and
there are two different approaches to the room to be heated until the pre-set tempera-
bronchoconstriction. ture is reached. Then, the thermostat switches off
the room heater. A similar mechanism occurs
with many hormones. There is a pre-determined
6.4.3 Systemic Corticosteroids level associated with health. When the hormone
level (in this case cortisol) falls below that level,
Systemic corticosteroids are included here then the tropic hormone which is produced by the
because of their role in severe, life-threatening pituitary gland (in this case adrenocorticotrophic
asthma. Much of the information below is also hormone or ACTH) and which stimulates the
relevant to their use in long-term difficult-to- production of the hormone in the adrenal gland is
control asthma and will not be repeated later. increased. Once the cortisol level in the blood-
Corticosteroids are effective in asthma for a stream has increased, release of ACTH from the
number of different reasons. For example, they pituitary is lessened as there is no longer a need
decrease the release of mediators from the alveo- to stimulate the adrenal gland to produce more
lar cells, reduce cytokine release, and decrease cortisol.
In other words, adrenocorticotrophic hormone • Moon face

(ACTH), the hormone in the pituitary gland that • Hirsutism
stimulates the adrenal gland to produce cortisol, is • Insomnia
released. When the body requires corticosteroids,
ACTH levels increase and stimulate the adrenal 6.4.3.1 Side Effects of Systemic
glands to produce more cortisol. As more cortisol Corticosteroids: Some
is produced by the adrenal gland, following the Comments
servo loop principle, the action of the pituitary While severe untreated asthma, by itself, may
gland is suppressed, and therefore less ACTH is lead to growth suppression, growth suppression
produced. Corticosteroids given in asthma imitate is also known to occur in children on long-term
the action of cortisol, “fool the pituitary gland,” systemic corticosteroids. In the past, oral or sys-
and thus less ACTH is released into the blood- temic corticosteroids (OCS) were used for the
stream. The net result is that anyone taking oral most severe cases. It is likely that in many cases
corticosteroids (OCS) on a daily basis, including there was no reduction in final adult height,
those with asthma, will suppress the production though there was some delay, during puberty, of
and release of ACTH and the adrenal glands will growth spurts, resulting in apparent short stature
have no stimulus to produce their own cortisol. As at specific moments in time. Growth suppression
a result, the adrenal gland may atrophy with the may occur because of a number of mechanisms,
long-term use of OCS. This has important impli- some unknown, but what is known is that produc-
cations. At a time of major stress, the person will tion of growth hormone will be impaired particu-
be unable to produce the extra cortisol needed. larly if the corticosteroid is given daily. Growth
This atrophy will affect not just the adrenal gland suppression will occur if the asthma is left
but also the hypothalamus and pituitary, the so- untreated.
called hypothalamic-pituitary-adrenal (HPA) axis. Bone metabolism and calcium metabolism are
OCS are powerful hormones, related to the also affected. Osteomalacia and osteoporosis
hormones produced in the body, and with a num- may occur, and bones will fracture with minimal
ber of well-recognized side effects. They can also force [11].
be affected by other medications that increase or Cataracts may occur, and adults on long-term
decrease their effectiveness. They have many systemic corticosteroids should have regular eye
potential side effects, some of which are very examinations to test for this condition.
serious. The major side effects [9, 10] include: Diabetes may result from a change in glucose
metabolism caused by the corticosteroids. If dia-
• Adrenal suppression betes symptoms exist, appropriate testing and
• Impaired bone metabolism management will be required.
• Linear growth delay in children OCS may impair the immune response; with
• Cataracts high doses, this impairment may lead to unusual
• Diabetes infections. However, this side effect, though theo-
• Infection retically possible, is rare. In children, the impair-
• Myopathy ment of the immune response may mean that a
• Hypertension common illness such as chicken pox may be more
severe when it occurs in children with asthma on
Less medically important side effects, but often OCS than in other children not on OCS.
very important to those with asthma, include: Myopathy, or muscle weakness, may occur
with OCS use. It is characterized by weakness,
• Bruising wasting, and changes within muscle cells.
• Weight gain Blood pressure may rise with regular use and
• Mood change should therefore be monitored. Other OCS side
• Acne effects include weight gain, bruising, and swell-
6.5 Long-Term Asthma Control Medications 183
ing of the face, known as moon face. Moods may situation, control over the asthma can usually be
change quickly from depression to euphoria to regained within 24 hours. At the same time,
aggression (emotional lability). Excess hair effective prophylactic treatment can be started.
growth on the face and body may be present. In summary, OCS remain important in the
OCS also increase the incidence of acne and treatment of severe asthma. Their use is best min-
insomnia. Some children become hyperactive imized, not by arbitrarily reducing the dose, but
when put on systemic corticosteroids. by careful attention to all of the details of asthma
Thus, the side effects of OCS are a major issue management, including environmental control,
in the treatment of asthma. At the same time, it is correct use of a prophylactic drug, and detailed
important to recognize that they are life savers in teaching of a delivery system, all described in the
many situations. Hence, they should only be con- next section.
sidered when other options have been explored
and rejected.
It is also important to realize that the metabo- 6.5 ong-Term Asthma Control
L
lism, and therefore the actions, of corticosteroids Medications
may be affected by many other medications, pre-
scribed and over-the-counter alike. The interaction There are boundaries between the various classes
will vary from one preparation to another, and in of medications, but these are sometimes blurred.
some cases, the benefits of the OCS will be at least For example, an individual with asthma may
partly lost, while in other cases, the action will be manage very well without regular medication.
more marked. Obviously, the reverse is also true, That same person may use inhaled corticoste-
and the benefits of a medication used long term for roids, designed for long-term prophylaxis, for a
another condition may be lost. When OCS are pre- week or so during a viral-induced exacerbation.
scribed, a full medication history is essential. The combination product budesonide/formoterol
Direct questions must be asked, as OTC prepara- may be taken twice daily as prophylactic therapy
tions such as Pepsin, Rolaids, and Tums are rele- and also be used occasionally to provide immedi-
vant. Many birth controls pills and antibiotics ate relief from breakthrough symptoms [2].
affect OCS actions. In addition to asking the per-
son with asthma about concurrent treatments, a
pharmacist should be asked to check any potential 6.5.1 Inhaled Corticosteroids (ICS)
effects on any medication in use.
Inhaled corticosteroids [12, 13] suppress airway
6.4.3.2 Use of Systemic Corticosteroids inflammation and are used almost exclusively in
in Severe Acute Asthma the long-term prophylaxis of asthma. ICS were the
OCS continue to be essential in crisis interven- mainstay of asthma management in previous
tion. When developing an asthma management guidelines, and if asthma control was incomplete
plan with an individual who has moderate or while on ICS, poor adherence was commonly con-
severe asthma, OCS (prednisone 40 to 60 mg/ sidered, and if adherence was assured, an increase
day) may be used when peak flow falls to 50% of in ICS dose was often the option of choice. The
its usual value. In children, a rough guide to pred- new NHLBI Guidelines [2] suggest changes to the
nisone dose is 1–2 mg/kg/day, to a maximum of paradigm of focusing almost exclusively on ICS at
60 mg/day. Dexamethasone may also be used in both ends of the severity spectrum.
children, 0.6 mg/kg given at onset and repeated For those with severe asthma, an important
24 hours later. The use of OCS should be limited, development is that there are now a number of
but not to the detriment of asthma control. effective and safe immunomodulators, which
In severe attacks, when prophylaxis has not will be discussed later. At the other end of the
been attempted or has not proved effective, or the spectrum, there are also changes in the approach
exacerbation is severe, OCS are essential. In this to those with mild asthma who have only
o ccasional exacerbations. Such individuals the minimum dose is found that controls
would have been treated with daily ICS even symptoms.
when well, with SABA and OCS added in exac- ICS may be used for extended periods. Many
erbations and perhaps with an increase in ICS individuals with asthma do not agree with (or do
dose. Now a new option is to avoid regular, not understand the need for) long-term use and
everyday therapy. Instead, at the early stages of will stop taking them after a few months of treat-
an exacerbation, ICS can be started with or with- ment. If symptoms do not recur, they will not
out SABA and continued for a week or so. The restart the drug; if symptoms recur, then they
implications of these two changes will be dealt have a stimulus to continue.
with in detail later. While side effects are uncommon, they vary
ICS are extremely effective. They decrease from mild to potentially severe, the latter being
airway inflammation and airway hyperrespon- related to systemic absorption. With high-dose
siveness, improve lung function, decrease symp- ICS, there may be a systemic effect, and some of
toms, and reduce mortality [14–21]. They may the side effects associated with systemic cortico-
also interfere with arachidonic acid metabolism steroids may be seen. Some growth suppression
and with synthesis of leukotrienes and prosta- has been shown in children on very high doses of
glandins and prevent the migration of inflamma- ICS. Most clinicians believe that when the ICS is
tory cells. In addition, ICS may increase the stopped, the growth rate will increase. The issue
responsiveness of beta-receptors in the airway of growth is very complex, as children with
smooth muscle. Because they also help by reduc- asthma may have growth retardation if treatment
ing the number of inflammatory cells, individuals is inadequate. Studies [22–24] have shown that
with asthma should be started on ICS when newly there is decreased velocity in growth during the
diagnosed, either every day or in exacerbations first year of treatment in children. However, when
[2, 21]. followed through to adulthood, there was no
ICS may be given by MDI, by nebulizer, or by significant difference in height between children
DPI, and it can take up to 2 weeks before signifi- who had used inhaled corticosteroids and those
cant effects on symptoms are noticeable, although who did not have asthma. Growth and develop-
some effect is commonly seen sooner. Their ment should be monitored, and if growth delay is
action subsides a few days after the medication noted, a full medical evaluation is indicated. In
has been discontinued. The starting dose of ICS the elderly, high-dose ICS may increase the risk
should be sufficient to control symptoms, and of cataracts [25] and slightly increase the risk of
therefore the assessment of severity is important glaucoma. In all groups, there is concern about
to determine what that dose should be. It is often adrenal suppression and inadequate response to
higher than the intended maintenance dose—for stress.
example, while a person might stabilize eventu- ICS are not all the same in terms of systemic
ally on 100 micrograms per day, the usual start- side effects. Lipworth examined available studies
ing dose will be between 400 and 1,000 of systemic adverse effects of ICS and wrote that
micrograms, depending on the potency of the “Marked adrenal suppression occurs with high
ICS. If the medication is taken correctly, as noted, doses of inhaled corticosteroid above 1.5 mg/d
there will be improvement in 1 to 2 weeks. (0.75 mg/d for fluticasone propionate), although
Once good control has been achieved, the there is a considerable degree of inter-individual
dose should be reduced slowly. The time interval susceptibility” [26]. There was greater “dose-
at which reductions are made varies considerably related adrenal suppression with fluticasone com-
from person to person. If there is severe life- pared with beclomethasone dipropionate,
threatening asthma, reduction should be made at budesonide, or triamcinolone acetonide.” In
intervals of 2 or 3 months or perhaps even longer. terms of adrenal crisis, Todd et al. noted that this
If the asthma is very mild, reductions may be occurred most commonly with fluticasone and
made quickly over a period of 2 or 3 weeks until suggested caution in the use of high doses of this
medication in children [27]. On the other hand, formoterol MDI or DPI, and long-acting alb-
when ciclesonide was compared with fluticasone, uterol as an extended-release tablet. Side effects
the former “achieves greater pulmonary deposi- become less with time as tolerance develops to
tion, causes fewer adverse oropharyngeal effects, beta-2 adverse effects, a phenomenon described
deposits less biologically active drug in the sys- earlier, and are typical of this class of
temic circulation, and has less potential for adre- medications.
nal suppression” [28]. The safety of ciclesonide Long-acting beta-agonists (LABAs) should
has been confirmed in adults [29]. not be used as monotherapy in asthma [34] but as
The more common side effects seen with ICS add-on therapy [35] in both moderate and severe
are oral thrush and dysphonia (hoarseness). Oral persistent asthma when the asthma is not con-
thrush can usually be prevented by using a spacer trolled despite the use of ICS and adherence to
and rinsing the mouth after inhalation. Hoarseness environmental measures. Combination products,
can be prevented by reducing the dosage of ICS, described in Sect. 6.5.4, are available that conve-
if this is considered safe, or spreading the dose niently contain both an ICS and a LABA.
throughout the day in smaller individual amounts.
When there is a perception of poor control
with a particular dose of ICS, many prescribers 6.5.3 Long-Acting Muscarinic
will respond by increasing the dose. To a certain Antagonists (LAMA)
level, this will be successful. The dose-response
curve rises steeply with an increase from low to The use of the shorter-acting anti-cholinergic was
moderate doses of ICS. However, it then starts to described earlier. There has been interest recently
flatten, and further increases in ICS dosage may in the role of the neurotransmitter acetylcholine
not only be relatively unsuccessful, but also raise in asthma. Acetylcholine is released from para-
the risk of side effects. In the case of the ICS sympathetic nerves and interacts with M3
fluticasone, a recent meta-analysis showed that muscarinic receptors in the lung, airway ganglia,
most of the therapeutic benefit was obtained with nerves, smooth muscle, mucous glands, and
total daily doses of 100–250 micrograms, with a endothelium of pulmonary blood vessels. The
maximum benefit at a dose of around 500 micro- effect is to increase airway tone, contract bron-
gram/day. As noted, while there may be modest chial smooth muscle, and reduce mucus secretion
benefit at doses above this level, it has been and vasodilation. Acetylcholine also plays a role
shown that it is better to add another drug (e.g., a in inflammation, by inducing the release of pro-
long-acting beta-2 agonist or leukotriene antago- inflammatory mediators. Hence, medications that
nist) and re-emphasize environmental control, can block these actions for an extended period
rather than prescribe even more inhaled cortico- may have an add-on role when the asthma is dif-
steroids [30–32]. ficult to control with low to moderate doses of
ICS along with LABA. Such a medication will
also be helpful when side effects of a LABA are
6.5.2 Long-Acting Beta-Agonists troublesome.
(LABA) The muscarinic antagonists induce broncho-
dilatation and perhaps reduce inflammation by
Long-acting beta-agonists are related chemically competing with acetylcholine at the muscarinic
to the short-acting beta-agonists. They relax the receptors. The use of these medications has been
smooth muscle, with an onset of 30 minutes or studied in people with COPD, and the five cur-
less for salmeterol and 2–3 minutes for for- rently licensed for use in this condition are
moterol and a duration of action that is 12 hours ipratropium, aclidinium, glycopyrronium (also
or longer [33]. Because of its speedy action, for- known as glycopyrrolate), umeclidinium, and
moterol can also be used for quick relief. Three tiotropium. For asthma, only two anti-
medications are currently available—salmeterol, cholinergics have been approved: ipratropium
and tiotropium [36]. The short-acting ipratro- Various studies have raised concerns that the
pium has been described above. As of the end of use of LABA as monotherapy increases the risk
2020, only tiotropium has been approved for use of acute hospital admissions due to asthma and
in the treatment of asthma in adults as add-on perhaps an increase in asthma mortality. The lit-
therapy to ICS and a LABA in a number of coun- erature is certainly contradictory, and an FDA
tries worldwide, including the European Union, meta-analysis did not settle the issue [39].
Japan, and the USA [37]. Tiotropium is the only Nevertheless, given the concerns, the use of the
long-acting anti-cholinergic approved for use in combination product means that those with
asthma. asthma cannot take a LABA by itself and that it
Available evidence was further reviewed in must always be combined with an ICS.
the recent guidelines update [38]. The studies A more general concern about treating asthma
covered people more than 12 years old. The real- without an ICS (or alternative long-term control-
world impact of LAMA on asthma is not yet ler), i.e., using beta-agonists as monotherapy,
clear as “the majority of LAMA studies used a extends backs to the 1960s [40]. This legitimate
comparative efficacy design, and not an effective- anxiety is alleviated by the availability of these
ness design, but the key questions were about combination products.
effectiveness.” In the situation when asthma is The use of an ICS in one inhaler, and a LABA
not controlled on ICS alone, the recommendation in another inhaler, might have the same benefit as
was to add a LABA rather than a LAMA. Having a combination inhaler. It is intuitively obvious that
said that, a LAMA can still be used as an add-on adherence is likely to be enhanced with a combi-
to ICS in individuals aged 12 years and older nation product, and this has been confirmed [41].
with uncontrolled asthma. It should be explained More recently, a new approach has been sug-
to them that add-on LABA therapy has a more gested—that of using one combination inhaler on
favorable benefit-harm profile. And as a precau- a regular basis and using the same inhaler as a res-
tion, it should be noted that “individuals at risk of cue inhaler [42]. Using the combination inhaler in
urinary retention and those who have glaucoma this way is another strategy to improve adher-
should not receive LAMA therapy.” However, as ence. Obviously, this strategy can only be used
in most newer preparations, the role of LAMA when the LABA in the combination product has
will evolve as more robust real-life evidence immediate onset, as in formoterol in Symbicort.
becomes available.
6.5.5 Leukotriene Receptor

6.5.4 Combination Products Antagonists (LTRA)
Fixed-dose combination products, i.e., an ICS + Leukotrienes [43, 44] are important mediators in
LABA in one inhaler, have been available for the pathogenesis of asthma. They have a potent
almost two decades. Fluticasone/salmeterol bronchoconstrictive effect that is 1000 times
(Advair™) was introduced in the UK in 1999 and more powerful than histamine [45–47]. They
the USA in 2000; budesonide/formoterol have been shown to increase white blood cells in
(Symbicort™) in Sweden in 2000 and the USA lung tissue and facilitate the leakage of fluids into
in 2006; and mometasone/formoterol (Dulera™) tissue. This adds to inflammation and swelling
in the USA in 2010. There is a difference in the and also gives irritants in the fluids access to the
onset of action of the LABAs used. Salmeterol tissues and muscles around the airway. Evidence
has a delay of about 30 minutes before the onset also suggests that leukotrienes increase mucus
of its bronchodilation. By contrast, formoterol production. Thus, attempts have been made to
starts working almost immediately and, as identify substances which would block their
already discussed, can be used for symptomatic action and which can be taken with safety. These
relief. substances are called leukotriene inhibitors or
leukotriene receptor antagonists (LTRA). They dence of adverse events and discontinuations
are active in preventing both the early and late from therapy were similar in the montelukast and
asthmatic response [48, 49]. placebo groups.” Similarly, in 698 children with
There are currently three leukotriene receptor asthma aged 2–5 years in a double-blind study
antagonists (LTRA) in use: with placebo, breakthrough asthma “occurred
significantly more frequently in the placebo
• Zileuton, which inhibits one of the early steps group” [51]. As in the previous study, “there were
in the formation of leukotrienes no clinically meaningful differences between
• Montelukast, which binds to leukotriene treatment groups in overall frequency of adverse
receptors effects or of individual adverse effects.”
• Zafirlukast, which binds to leukotriene receptors Pregnant women with asthma, and their health-
care providers, are concerned about the use of any
The NHLBI Expert Panel Update classifies medication. As always, the risk of inadequate treat-
leukotriene inhibitors as an addition to, but not a ment of asthma, and consequent risk to the fetus of
replacement for, inhaled corticosteroids for per- possible hypoxemia, must be balanced against
sons with moderate persistent asthma [35]. potential risks of the medication. It is impossible to
Despite being available since the 1990s, the pre- be certain that montelukast is absolutely safe dur-
cise role of the LTRAs in asthma management ing pregnancy, and given the many alternatives to
remains unclear [49]. It is reasonable to use an LTRA, the issue may not be raised very frequently.
LTRA in asthma when ICS alone will provide If a woman with asthma on LTRA becomes preg-
inadequate control, although use of a combina- nant, some modest reassurance can be given from a
tion product (ICS + LABA) will be more effec- Danish study [52], which noted that “pregnant
tive and obviously more convenient. women with prescriptions for montelukast had a
When there is inadequate control with an ICS/ higher risk of pre-term birth and maternal compli-
LABA combination, and all the usual provisos, cations.” However, as the authors point out, these
such as adherence, ability to use an inhaler, risks are also associated with maternal asthma
finances, comorbidities, and alternative diagnoses without LTRA. There was no increased risk of con-
and other conditions, have been dealt with, then genital anomalies. In the same vein, a recent study
adding an LTRA is a reasonable step before showed very low levels of montelukast in infants
increasing the dose of ICS. Despite the proven breast-fed by mothers receiving LTRA [53].
effectiveness and safety of ICS, there remains a Having noted a low incidence of side effects in
small population of people with asthma and par- the original studies, a concern has arisen over the
ents of children with asthma, who have a great fear last several years about neuropsychiatric side
of corticosteroids (corticophobia). In such a situa- effects. Based on case reports received by the US
tion, LTRA might be used in conjunction with Food and Drug Administration (FDA), a “black
low-dose ICS in consultation with the person with box” warning has been placed on montelukast.
asthma or their family over time to provide reas- This is a warning that appears on the medication
surance about the safety of ICS. In those unable to label and is “to call attention to serious or life-
use an inhaler, LTRA should be used before resort- threatening risks.” In the case of montelukast,
ing to OCS. There may also be a role for LTRA this is about serious neuropsychiatric (NP) events
when stepping down or reducing the dose of ICS, reported in those with/without a history of psy-
with careful monitoring, of course [35]. chiatric disorder during montelukast treatment
The most commonly used LTRA is montelu- and after its discontinuation. The events include
kast, and it seems safe, with one exception that agitation, aggression, depression, sleep distur-
will be discussed later in this section. In a double- bances, and suicidal thoughts and behavior
blind study of 681 individuals with asthma over (including suicide). There was great variability in
the age of 15 years, efficacy was shown [50]. In the NP event types reported, and it is unclear
addition, the investigators noted that “the inci- what, if any, are the underlying mechanisms [54].
Concerns were also noted in data from the 6.5.6 Immunomodulators

WHO database of 14,670 reports on montelukast and “Precision Health”
[55]. The main symptoms were sleep disorders
(infants aged less than 2 years), depression/anxi- Immunomodulators are medicines intended to
ety (children aged 2–11 years), and suicidal “help regulate or normalize” the immune system
behavior and depression/anxiety (adolescents [62]. They are employed in many areas of health-
aged 12–17 years). Thus, there are worrying care, but this section will focus on those used as
concerns, but an important caveat is that these add-on therapy in asthma.
are passive reports, with clear limitations on The immunomodulators currently available
being able to attribute causality, rather than asso- for asthma are monoclonal antibodies, an entirely
ciation. Formal studies have given varying new class of medication being used across the
results, with some showing no NP events [56, spectrum of medicine—in cancer, rheumatoid
57]. In a case-controlled study of 898 NP cases arthritis, multiple sclerosis, and other diseases—
in children, where each child was matched to 4 and now available specifically for asthma. They
controls, there was a statistically significant are an exciting addition to current therapies and
increase in NP events in those newly prescribed have a specific role when asthma is severe enough
montelukast [58], but the events were mainly to require very-high-dose inhaled corticosteroids
anxiety or sleep disturbance. In a nested cohort or systemic corticosteroids. Their development
study, NP events were confirmed, especially in and rational use follow a deeper understanding of
the first few weeks [59]. the pathogenesis and genomics of asthma.
The LTRA Zileuton does require that liver Given the novelty of this new class of medica-
enzyme testing be done before treatment com- tions, some general background information is
mences and every 2 to 3 months while treatment essential. The monoclonal antibodies are part of a
is in progress. If theophylline is used, more fre- larger group of new compounds called biologics,
quent monitoring of theophylline levels is essen- developed using biotechnology, with an origin
tial. Zafirlukast affects the body’s handling of from human or animal tissue or from a microor-
warfarin and should not be used in anyone on this ganism. Monoclonal antibodies (mAb or moAb)
medication [60]. This effect was not seen with are made by cloning a unique white blood cell,
montelukast [61]. which is ultimately the origin for every antibody
How should the asthma educator or asthma derived in this way.
prescriber respond to this information? Use At a basic level, an antibody is a protein made
basic principles that apply to all medications. by the immune system to attack an antigen, which
That is, use a medication that is most appropriate is also a protein. Monoclonal antibodies are
for the specific situation in a specific individual, designed in a laboratory to attack very specific
warn about side effects, and ensure ongoing antigens, and their name suffixes indicate their
assessments that include appropriate monitor- primary source: antibodies made from mouse
ing. And of course, medications should be protein have names ending in “-omab”; part
stopped when no longer required or when there mouse and part human protein, “-ximab”; small
is a suspicion of side effects and an alternative is parts of most protein attached to human footing,
available. Great care should be taken with initial so-called humanized “-zumab”; and fully human
prescriptions and ongoing monitoring of monte- proteins, “-umab.”
lukast given the presence of a “black box warn- The starting point in the development of a
ing” regarding neuropsychiatric side effects. monoclonal antibody for any health condition is a
This medication should be used when there are detailed knowledge and understanding of causal
no reasonable alternatives, only after a warning mechanisms. The use of any specific monoclonal
has been given regarding side effects, and ques- antibody in asthma requires knowledge of pheno-
tions asked about behavior/psychiatric issues at type and endotype in individuals with asthma, as
every visit. described earlier in the book. Specifically, the
understanding of the role of IgE and of interleu- steroids regularly and then to adjust the dose
kins such as IL5 was helpful in the development according to the response. Currently, the use of
of the first two monoclonal antibodies for asthma, monoclonal antibodies in asthma is following the
omalizumab (anti-IgE) and mepolizumab (anti- traditional path: all possible attempts are made to
IL5). More of the currently available monoclonal control the asthma using current therapeutic
antibodies are listed in Table 6.1, and many more agents, avoidance strategies, and control of aller-
are in development. gies and other comorbidities. Monoclonal anti-
The use of these new compounds is part of body treatment is considered only if the asthma
what is called “precision health” or “precision remains problematic after all conventional steps
medicine,” in which both treatment and preven- have been tried and discarded.
tion are patient-specific. While the term “preci- In the future, precise classification of the indi-
sion health” may be new, the underlying principle vidual and the asthma can be expected, and some
is not: in the past, knowledge permitting, preci- people will be identified very early as being
sion was used in treatment. Consider blood trans- unlikely to respond to conventional therapy,
fusions: originally blood would be withdrawn including the use of ICS and additional medica-
from the nearest available donor, but once blood tions such as LABA. Precise classification will
typing and serology were understood, a donation require continued research into the genetic and
was always taken from a matching donor. biochemical basis of asthma and the specific
The “precision health” approach is based on genomics of each individual. In addition, the spe-
knowledge of individual variability in genes, cialized discipline of pharmacogenomics, the
environment, and lifestyle. Until recently, this study of how genes affect any one person’s
was not the case: the general approach was to use response to any one specific medication, will
treatment considered the most appropriate for come to the fore. There are hence many steps to
most people; if it proved unsuccessful, then other be taken before a full realization of the benefits of
options were tried. That approach led to delays, precision health will be seen in the management
complications, and, sometimes, death. of asthma. New privacy safeguards will also be
Where precision health is already well-developed, required, since precision health will depend on
accurate information allows the best treatment to be the sharing of large data sets of confidential
determined in advance and used first. Rather than information. Given that a specific treatment
employing the old trial-and- error approach, treat- might be designed for a specific individual, new
ment is aimed very carefully at one target. research designs will be needed, and novel and
The contrast between accurate pre-transfusion rigorous ways of oversight by the various drug
matching of blood types and what has been done regulatory authorities will be demanded.
to date in asthma is clear. Until recently, asthma Successful partnership of scientists from many
education was mainly an attempt to persuade disciplines is required and between healthcare
people with asthma to take their inhaled cortico- practitioners must also be developed.
Table 6.1 Monoclonal antibodies for asthma

Name Binds to Age Route Dosing Administered
Xolair IgE >6 SC Based on IgE level and body weight In clinic or at home
(omalizumab) yrs
Nucala IL-5 >6 SC Every 4 weeks At home
(mepolizumab) yrs
Cinqair IL-5 > 18 IV Every 4 weeks In clinic
(reslizumab) yrs
Fasenra IL-5R >12 SC Every 4 weeks for first three doses and At home
(benralizumab) yrs then once every 8 weeks
Dupixent IL-4Rα, IL-4, >12 SC Every other week At home
(dupilumab) IL-13 yrs
To return to current concerns: monoclonal were designed to target inflammation in the air-
antibodies should be considered whenever severe ways. It is administered as a subcutaneous injec-
asthma remains uncontrolled despite adherence tion on a monthly basis. It can also be given
to an excellent treatment regimen. At this very intravenously [66, 67]. Pre-filled syringes of
early stage, statements such as “everyone with omalizumab (XolairTM) are now available.
asthma is different” do not come close to describ- Given that omalizumab has been longest in
ing the true heterogeneity of the disease. While use, there is a greater body of knowledge about it
bronchial obstruction is still the ultimate cause of than about the newer products. The approach to
symptoms, and this measurement will remain the its use will be described in detail and will act as a
key factor in asthma assessment, other measure- template for the use of the newer monoclonal
ments will become more relevant. The focus cur- preparations.
rently is on airway inflammation, and that Omalizumab’s use is limited, specific, and very
described as Type II seems most likely to be the important. It is for people with moderate to severe
target of monoclonal antibodies. Type II shows asthma who are inadequately controlled on inhaled
evidence of eosinophilic involvement, associated corticosteroids and on whom all the usual proce-
with high IgE and a variety of interleukins [63]. dures in the assessment of control have been car-
The monoclonal antibodies will bind to block key ried out. As noted above, it binds to IgE and
parts of the inflammatory pathways. There will reduces the release of allergic mediators. It is
therefore be much less inflammation and as a hence reserved for persons with proven allergies
consequence improved control of the asthma and and raised serum IgE levels. The dose prescribed
future symptoms in the individual [64]. is based on body weight and serum IgE level.
Immunomodulators are a new class of “add- Omalizumab is effective in reducing both the
on” drug available for moderate to severe asthma. number of exacerbations and the dose of inhaled
They are biologics, made from living organisms, corticosteroids [68–71]. Studies show an
and act on the immune system. The immunomod- improvement in the quality of life in children
ulators used for asthma are monoclonal antibod- [72] and adults [73, 74]. It is licensed for those
ies that bind to a particular target of the immune aged 6 years and above. It has also been tested in
response. The targets affected by these medica- the treatment of perennial allergic rhinitis and
tions include immunoglobulin (IgE) and cyto- found to provide effective control of symptoms,
kines. The available immunomodulators and reduced reliance on antihistamines, and improved
their targets are listed in Table 6.1. quality of life [75].
The other biologics have not been used or
Immunomodulators for Asthma studied as much, but enough information exists to
Most of these new asthma medications are realize they are very promising, but always as
approved for IgE (eosinophilic) asthma. High lev- add-ons. It should also be noted that they are all
els of IgE are a marker of asthma in most cases. expensive.
Blocking IgE might be helpful, although this does
not necessarily imply a causal relationship [65]. Side Effects
The first monoclonal antibody to be approved, While the asthma biologics are generally well
omalizumab, is produced by recombinant human- tolerated, possible side effects do exist:
ized technology, hence the ending ‘zumab.’ It
binds to and blocks IgE, neutralizing it and reduc- • Omalizumab (Xolair) may cause arthralgia,
ing airway damage. It prevents IgE from attach- generalized pain, leg pain, fatigue, dizziness,
ing to mast cell receptors, significantly reducing fracture, pruritus, dermatitis, and earache.
the release of histamine. It interrupts the allergic • Mepolizumab (Nucala) may cause injection
reaction earlier than other medications, which site reaction, headache, back pain, and fatigue.
• Benralizumab (Fasenra) may bring on head- (d) Are there risks or triggers that can be

ache and pharyngitis negated or minimized both at work and at
• Dupilumab (Dupixent) users may experience home, such as:
injection site reactions, oropharyngeal pain, (i) Smoking (including second- or
eosinophilia, conjunctivitis, blepharitis, oral third-hand smoke)
herpes, and keratitis. (ii) Environmental exposures to irritants
• Reslizumab (Cinqair) users may have oropha- (iii) Allergen exposure known to cause
ryngeal pain. sensitization
(iv) Use of medications such as beta-
Both omalizumab and reslizumab carry “black blockers or ASA
box” warnings regarding anaphylaxis. In the case of (e) Is SABA being overused?
omalizumab, safety has been evaluated in over 4,000 (f) Are asthma medications leading to dis-
individuals with asthma. It has triggered anaphylaxis tressing side effects?
in a small number of them, usually within 2 hours of (g) Are there psychosocial issues (anxiety,

administration. However, it has been known to cause depression and problems with social rela-
anaphylaxis even 2 years after administration. Hence, tionships, social isolation)?
anyone prescribed omalizumab (or reslizumab) 3. Ensure that current management is optimal.
should also be prescribed an epinephrine injector and Action should reflect concerns listed in Step 2
taught how to use it. The other most serious adverse above.
reaction is various forms of malignancies. (a) Insist on asthma education, even if done
previously.
Determining Suitability of Biologics: The (b) Check and correct inhaler technique and
Process The GINA Guidelines [1] are helpful in encourage adherence with tips on how to
approaching so-called difficult-to-treat asthma; do this.
NHLBI Guidelines are silent. The GINA (c) Switch to ICS-formoterol maintenance
Guidelines focus on “adolescents and adults with and reliever combination therapy.
symptoms and/or exacerbations despite GINA (d) Treat all identified comorbidities, and

Step 4 treatment or taking maintenance OCS.” ensure risk factors are eliminated or
While the process has been outlined several times reduced.
already, it is described in more detail here. (e) Consider add-on therapy if not already in
use, such as LABA, tiotropium, LAMA,
The process to be followed when considering or LTRA.
the use of a monoclonal antibody is: (f) Encourage non-pharmacological inter-
ventions, including smoking cessation,
1. Confirm that the diagnosis is correct and that weight loss, exercise, mucus clearance,
no other another condition could be responsi- and annual influenza immunization.
ble for the symptoms. (g) Consider high-dose ICS if not already in
2. Explore in detail the possibility of specific use.
factors contributing to symptoms and increas- 4. Perform a review in 3–6 months.
ing the possibility of exacerbations adversely (a) If asthma remains uncontrolled, then
affecting quality of life: severe asthma is confirmed, and proceed
(a) Is inhaler technique correct? to “Determining suitability of
(b) Is medication actually being taken as
biologics – confirmation”.
prescribed? (b) If asthma is controlled, consider reduction
(c) Are there comorbidities such as obesity, in treatment, with OCS being reduced
GERD, chronic rhinosinusitis, and OSA? first if they are in use:
(i) Perform close follow-up, and if deterio- (e) Determine whether there is a registry or
ration occurs, return to previous regi- clinical trial that the person may enroll in
men, accepting that this is severe at little or no cost.
asthma, and proceed to “Determining 6. If severe asthma phenotype is confirmed, and
suitability of biologics – confirmation.” all other possibilities are discounted, use
(ii) If asthma remains under control, then biologics.
monitor closely, reducing therapy Once the decision to prescribe biologics has
slowly, ensuring control is maintained. been made, other complications may arise:
5.
Determining suitability of
biologics – confirmation • The high costs involved, since many drug
Having diagnosed severe asthma, the HCP plans may not cover these products
should perform a full assessment, but con- • Variations in product availability between
tinue with high-dose ICS (or lowest OCS countries
dose) during assessment. • Difficulty in choosing the best biologic for the
(a) Re-confirm presence of Type 2 inflamma- job
tion through the presence of one or more • The choice of product will be difficult.
of the following: There are no objective, standard-baseline
(i) Blood eosinophils ≥ 150/μl comparisons between the various biologics
(ii) FeNO ≥ 20ppb that can be used as an evidence-based guide
(iii) Sputum eosinophils ≥ 2% to the choice of medication. In addition,
(iv) Clinical features of the asthma based studies done to date have used varying
on allergies inclusion/exclusion criteria and outcomes.
(v) Need for maintenance OCS, with Nevertheless, a rough guide would be as
tests i and ii above repeated on low- follows:
est possible OCS dose (a) Anti-IgE if: sensitization (skin tests or
(b) Investigate comorbidities and differential specific IgE), total serum IgE and weight
diagnosis by performing: within dosage range, and exacerbations in
(i) Complete blood count (CBC), the last year
C-reactive protein (CRP)1, IgG, IgM, (b) Anti-IL5/anti-IL5R: exacerbations in the
IgE, fungal precipitins, chest x-ray, last year and blood eosinophils ≥ 300/μl
high-resolution CT of chest (HRCT), (c) Anti-IL4R: exacerbations in the last year
and diffusing capacity of the lungs + blood eosinophils ≥ 150/μl or FeNO ≥
for carbon monoxide (DLCO)2 25ppb
(ii) Formal allergy testing, either skin 7. While predictors of success with biologics
prick or specific IgE have been described, they vary in accuracy
(iii) ANCA3, CT sinuses, echocardio- and do not replace careful monitoring and
grams if required intermittent full reassessment.
(c) Ensure social/psychological support. (a) If response is good: if on OCS, these
(d) Ensure multidisciplinary team involvement. should be reduced first. If on inhaled ther-
apy, dose may be reduced, but do not stop
ICS. In general, medications should be
1
CRP is a protein made in the liver, and raised levels in the reduced slowly based on evidence of pre-
blood indicate inflammation. vious benefit, potential side effects, cost,
2
DLCO measures how well gases cross into the blood- and of course the preference of the person
stream from the alveoli and is low in emphysema and in who is actually receiving the medications.
interstitial and fibrotic lung diseases.
At the same time, do not forget to ensue
ANCA is anti-neutrophil cytoplasmic autoantibody, and
3
raised levels raise the possibility of autoimmune

management is optimized using the 1–3
vasculitis. steps above at every visit.
(b) If response is not good: stop biologic ther- tezepelumab with different phenotypes/endotypes
apy. Then: of asthma, should be addressed.” Some benefit
(i) Review the basics as already was shown in another study, but “tezepelumab was
described. unable to significantly reduce daily oral corticoste-
(ii) Consider HRCT if not already done. roid dose without loss of asthma control” [77].
(iii) Reassess phenotype. Tezepelumab will eventually become avail-
(i) Induced sputum. able. Amgen and AstraZeneca, the manufactur-
(ii)
Consider bronchoscopy for ing partners, intend to seek approval in 2021.
alternative diagnoses. Assuming approval is given, a predictable
(iv) Consider add-on macrolide. additional challenge to healthcare profession-
(v) Consider low-dose OCS, ensuring als that occurs with all medications (at least in
strategies in place to minimize the the USA and New Zealand) will be direct-to-
side effects. consumer advertising. This is likely to be the
(i) Consider bronchial thermoplasty. first source of information for many with
asthma and the start of a dialogue with their
Current biologics currently available are com- HCP or asthma educator. There are advantages
plex molecules that must be given by IV or SC in this mode of d isseminating information, but
injection. Most persons with asthma considered also some drawbacks. The topic is now so
for a biologic will have a long history of asthma, important that it is further discussed in Sect.
including IV medication as part of ED treatment of 8.11 along with strategies that educators might
exacerbations. As a result, needle phobia may have consider.
set in. Hence, whenever these medications are In summary, the biologics are not only new
considered, the presence or absence of needle pho- preparations, but part of a new approach, and fur-
bia must be explored and if present treated. Some ther experience in a variety of situations will help
asthma educators may have the skills to do this, establish their place over time. However, the
but often additional professional help is needed. problem the prescriber faces—because of the
Over time, more biologics will undoubtedly lack of head-to-head studies—is likely to remain
become available. The HCP will nonetheless have not only a reality but also a continuing source of
to perform individual assessment and will con- confusion and frustration.
tinue to face challenges in assessing the evidence
and deciding exactly which medication is likely to
prove beneficial in any one individual. An example 6.5.7 Long-Term Systemic
of the challenges involved is exemplified in what is Corticosteroids
happening in research and perhaps eventual licens-
ing of tezepelumab. This medication is not cur- Given the wide range of other effective and safe
rently approved, but may well be in the near future. medications, the use of OCS is no longer a
Tezepelumab was reviewed in 2019 [76]. It common strategy. There remain a few people
binds to TSLP (thymic stromal lymphopoietin), a with asthma severe enough that this last resort
cytokine overexpressed in the airways of those must be used.
with severe asthma and responsible for inflamma- It is more important when long-term systemic
tory responses in asthma. This binding inhibits the corticosteroids are being considered to ensure a
action of the TSLP receptor complex and poten- full evaluation. This evaluation, as described ear-
tially helps to lessen asthma symptoms. The lier, is so important it must be repeated at inter-
reviewers saw tezepelumab as a promising candi- vals in order to:
date to be used in asthma. However, there was a
caution: “Several unanswered questions concern- 1 . Confirm or re-confirm the asthma diagnosis
ing basic pathophysiological aspects of TSLP vari- 2. Address factors that might contribute to

ants, and the long-term safety and efficacy of uncontrolled asthma:
(a). Lack of finance/inadequate insurance diurnal variation is a common feature in human

coverage physiology, and the important one in asthma is
(b). Non-adherence the natural diurnal variation in the production of
(c). Poor inhaler technique corticosteroids and growth hormone. Larger
(d). Unidentified or poorly or untreated
amounts of both substances are produced at night
comorbidities such as gastroesophageal than during the day.
reflux Sudden stoppage of long-term corticosteroid
3. Give advice on the mitigation of occupational therapy can lead to withdrawal symptoms such as
and environmental triggers headaches, nausea, low blood sugar, muscle and
joint pain, restlessness and hypotension and, in
In addition, for the small number of users some cases, death. Corticosteroids should be
who continue to require OCS long term, the gradually reduced over a period of weeks. This
regimen should be optimized by determining does not apply in cases where treatment is being
the minimal effective dose and prescribing it for made with a short burst of oral corticosteroids
use in the morning on alternate days (a single (typically lasting less than a week).
dose at 7–8 a.m. every other day) where possi- Extra care must be employed for corticosteroid-
ble. These particular individuals require a much dependent individuals with severe asthma symp-
more wide- ranging assessment—one that toms. These persons have been shown to have a
should cover the many aspects of care, includ- higher incidence of psychiatric comorbidity [78].
ing psychosocial aspects. They also require full Cessation of corticosteroid therapy must be done
assessment of: under a healthcare provider’s supervision. Slow
reduction in the dose of corticosteroid allows the
• Pulmonary function hypothalamic-pituitary-adrenal (HPA) axis to
• Home and work environment recover, though symptoms such as depression
• Psychosocial status may occur.
Systemic corticosteroids have been used
And of course, frequent evaluation and re- extensively as long-term agents in the control of
evaluation must be done for side effects and to moderate to severe asthma. Their use has dimin-
ensure alternatives are being explored. ished in chronic asthma with greater knowledge
Many side effects have already been described, of environmental control and with the availability
but one specific form of immune suppression is of other pharmacological agents, which include
of concern in children. Chicken pox is a universal high-potency ICS, LABAs, immunomodulators,
infectious disease of childhood, almost always and LTRAs. The newer ICS and LABAs are
mild. It may turn severe in a child who is receiv- delivered effectively by modern delivery devices.
ing high doses of OCS. If a child on OCS has had Adrenal suppression, in particular, is much less
contact with a child with chicken pox, the parents common with ICS than with systemic corticoste-
should obtain medical advice immediately. roids, but as noted earlier, it does occur. Hence,
Particularly in children, the suppression of care in prescribing and ongoing monitoring is
growth hormone production and adrenal cortico- still an essential component of care.
steroids can be reduced (but not prevented) by
giving prednisone early in the morning—between
7 and 8 a.m. Note this is different from the use of 6.5.8 Theophylline
inhaled corticosteroids, which may be more
effective when given in the afternoon. References Though their use in the USA is currently very lim-
have been made earlier to the changes in asthma ited, the methylxanthine group of bronchodilator
that occurs between day and night. This so-called medications was the mainstay of US asthma man-
agement till recently. Usage in other parts of the [81] (that include inattention, hyperactivity, irri-
world has always been much less. The theophyl- tability, and behavior that is withdrawn or diffi-
line group consists of theophylline itself, amino- cult to control) to major cardiac effects and,
phylline, choline theophyllinate, and oxtriphylline, rarely, cerebral hemorrhage. Behavior and learn-
and their use has been continuously evaluated over ing problems have also been described in chil-
the last several years. The drugs remain low in dren, but these have been overemphasized.
cost, which is an obvious advantage. Theophylline Theophylline has a number of other effects in
is mentioned in the recent NHLBI Update but with addition to those on the smooth muscle [82]. It
an important qualifier that it was “not considered increases diaphragmatic contractibility. It cer-
in this update” and has “an increased risk of tainly acts on the heart and circulation and may
adverse consequences and need for monitoring stimulate respiration. It can also trigger or worsen
that make ... use less desirable” [2]. In other words, gastroesophageal reflux (GERD) as it increases
the therapeutic window between an effective dose gastric production and reduces the pressure of the
and a toxic dose is narrow, and the margin between esophageal sphincter which permits reflux of
an effective dose and one with side effects is small. gastric acid into the esophagus. Its use has been
The authors believe that with the current availabil- shown to increase GERD by 24% and to increase
ity of a wide range of more effective products, this the amount of reported heartburn and regurgita-
medication is not needed for successful asthma tion by 170% [83, 84].
management. In addition, the newer medications This medication is always administered orally
have a much lower risk of side effects, without the or by injection, and the usual theophylline prepa-
need for monitoring through frequent blood tests. rations currently available are of the extended-
Regardless, theophyllines are still in use, and release form. This permits administration just
details are provided to help ensure safety of those once or twice a day, with appropriate testing of
given this medication. levels to monitor adequacy of dosages. These lev-
Theophylline relaxes the smooth muscle and els are an indicator of adherence.
inhibits the release of mediators from mast cells. In using theophylline, the healthcare provider
It inhibits the late asthmatic response, and there is must:
evidence that it has some anti-inflammatory
action at low (about 5 ug/ml) serum concentra- • Consider the age of the individual
tions. There has been some interest in the possible • Proceed much more cautiously for children
benefits of this modest anti-inflammatory effect in under 5, and the elderly, than for other ages
COPD, but even this use seems forlorn [79]. • Determine whether the individual is a smoker
The onset of action of theophylline depends (smoking increases theophylline metabolism)
on the route and the dose, and the duration • Determine the individual’s level of obesity
depends on the dose. Generally, doses producing (whether thin or fat)
serum levels in the range of 5 to 15 micrograms/ • Ascertain whether any other ailments are pres-
ml [80] are required. Beyond this level, side ent that may affect drug activity, such as liver
effects occur, such as nausea, vomiting, head- disease, heart failure, or seizure
ache, nervousness, and tachycardia. As the level
rises, so does the severity of the side effects, and Theophylline can interact with, and be affected
these include all the preceding mild effects plus by, a large number of prescribed medications,
seizures leading to status epilepticus, refractory such as Tagamet, erythromycin, and ciprofloxa-
cardiac rhythms, severe hypertension, and possi- cin [85]. It may also cause gastroesophageal
bly death. reflux in the elderly and in children. Tables 6.2
Side effects are common and vary consider- and 6.3 list the medications that can increase and
ably, from minor changes in behavior in children decrease theophylline levels.
Table 6.2 Medications that INCREASE theophylline levels

Use Trade names
Alcoholism Antabuse
Birth control Brevicon, Enovid, Demulen, Genora, Loestrin, Nelova, Nordette, Ortho-Novum, Ovcon,
Ovral, Triphasil, and many others
Gout Lopurin, Zyloprim
Heart disease Adalat, Blocadren, Calan, Cardizem, Cartol, Dilacor, Inderal, Isoptin, Levatol, Mexitil,
Procardia, Timoptic, Verelan, Visken
Infections Antibiotics such as:
Biaxin, Cipro, Comprecin, EES, E-Mycin, Eryc, EryPed, Ery-Tab, Erythrocin, Floxin, Ilosone,
Noroxin, Pediazole, Penetrex, TAO
Parasites Mintezol
Stroke Ticlid
Ulcers Tagamet
Note: Cigarette smoking and marijuana as well as phenytoin therapy will increase theophylline clearance
Table 6.3 Medications that DECREASE theophylline levels

Use Trade names
Adrenal disease Cytadren
Sleep disorders Alurate, Amytal, Butisol, Lotusate, Mebaral, Seconal
Seizures Dilantin, Luminal, Mysoline, Peganone, Solfoton
Tuberculosis Rifadin, Rifamate, Rimactane
Note: Theophylline clearance will decrease with cirrhosis, cardiac failure, sustained fever, old age, neonates, and viral
infection
From an initial reading of the above descrip- a vailability for use in the United States, and/or
tion, it would appear that this is one drug to avoid. have an increased risk of adverse consequences
However, and despite all these side effects, it has and need for monitoring that make their use less
been used successfully over many years, and desirable.”
where healthcare providers have confidence in its Cromolyn (cromolyn sodium, IntalTM) and
use, they continue to do so with safety. Recently, nedocromil (TiladeTM) are both non-steroidal anti-
it has been suggested that in severe asthma, low- inflammatory medications that prevent mediator
dose theophylline may allow reduction in the release. In the case of cromolyn, only histamine
amount of ICS taken [86]. release is prevented, while nedocromil blocks the
However, every indication is that the decline release of many other mediators as well. The
in worldwide usage is likely to continue. medications inhibit the early and late phases of
allergen-induced bronchoconstriction and are
used in the long-term prophylaxis of asthma.
6.5.9 Cromolyn and Nedocromil Cromolyn may prevent exercise-induced
asthma. For such use, the drug needs to be taken 30
These medications are considered together. Both minutes before the exercise starts, and this delay in
were once popular, but are of low potency and onset of protection is a major drawback. When
therefore have a limited role, and there may be used for long-term prevention of asthma, between
problems in availability. They are mentioned in 3 and 6 weeks are required before it can be deter-
the most recent update, at the level of Step 2 but mined whether or not the drug is effective.
not at any greater level of severity [2, 38]. In Both cromolyn and nedocromil are adminis-
addition, there is a footnote, “Cromolyn, tered via inhalation, and both are available in
Nedocromil, LTRAs including Zileuton and MDI. Cromolyn is also available in nebulizer
Montelukast, and Theophylline were not consid- solution. Both products cause very few serious
ered for this update, and/or have limited side effects, mainly minor irritability, especially
with the powder inhaler, and an unpleasant taste ingly, once a diagnosis of asthma has been made
with nedocromil [86]. The efficacy of cromolyn and appropriate treatment taken, the “recurrent
has recently been reassessed, and it is doubtful if bronchitis” disappears, and the need for antibiot-
it has any more than a minimal effect on symp- ics ceases.
toms. Neither of these are the primary drug of
choice for the treatment of asthma, but may be
used in those individuals who are 6.7 Immunotherapy in Asthma
steroid-phobic. (“Allergy Shots”)
Some healthcare providers choose nedocromil
and cromolyn rather than inhaled corticosteroids. Immunotherapy in the form of “allergy shots”
These medications are useful when individuals or has been in use for many years, yet remains con-
their families are antagonistic to the use of ICS troversial with professionals [87]. In an attempt
because of a fear of side effects. Neither is par- to make patients understand immunotherapy in
ticularly potent, and some researchers have ques- familiar terms, allergy shots specifically have
tioned whether cromolyn has any benefit at all. been described as vaccinations to desensitize
With cromolyn, the major drawback is that it individuals to allergens (Vaccine Weekly, 1998,
needs to be taken four times a day; further, it is Dec 21). Currently immunotherapy may still be
only after 4 weeks of therapy that the healthcare delivered as subcutaneous injection (SCIT) or
provider can determine whether or not it is prov- “shots,” but use of sublingual immunotherapy
ing successful. Nedocromil must be taken three (SLIT) with drops is also possible.
times a day; while this is better than four times a Many allergists believe that immunotherapy
day, it is still a partial barrier to adherence. has been unfairly maligned. They note success
Nedocromil also has a very unpleasant taste. when a vaccine, carefully chosen and prepared,
Asthma can be safely and effectively managed follows assessment by a well-trained allergist.
without these medications. Individuals with asthma often find logic in SCIT,
The medications used in asthma, their side which offer the possibility of modifying the natu-
effects and the time needed before they are effec- ral history of asthma. Strong proponents of
tive are shown in Tables 6.4 and 6.5. immunotherapy believe that other treatments
. This is a repeat of the sentence that comes may provide control of asthma but do not funda-
before the tables. Please delete. mentally change it. In other words, immunother-
apy may be disease-modifying.
Given the controversy, it was appropriate that
6.6 ther Medications Used
O the 2020 Focused Updates to the Asthma
in Asthma Management Guidelines reviewed in detail the
role of subcutaneous and sublingual immuno-
Mucolytic medications, which are used to loosen therapy in the treatment of allergic asthma [2].
sputum, are available both over the counter and An essential prerequisite to immunotherapy is
by prescription. In general, these medications are demonstration of allergic sensitization by skin
not very effective, and conventional asthma treat- testing or by measuring antigen-specific IgE anti-
ment is more beneficial to most individuals. body in the blood. Immunotherapy by SCIT is
While acetylcysteine is effective, it irritates the something to be considered in adults and children
airways and must be given by nebulizer. over the age of 5 who:
Antibiotics are often given for acute asthma
exacerbations. While there are some genuine • Have well-controlled allergic asthma and wish
indications for their use, such as sinusitis, they to reduce the burden of medication
are generally not helpful. Many individuals are • Have a history of worsening symptoms with
diagnosed with asthma after years of taking anti- specific seasons
biotics for “recurrent bronchitis.” Not surpris-
Table 6.4 Medications used to manage asthma
198
Generic Name Packaging Strength(s) Dosage Comments

Beta-agonists (short acting)
Albuterol MDI 90 mcg/dose Child: 2 puffs tid-qid prn or 1–2 Dose may be given until mild
Proventil puffs prior to exercise effects such as tremor are seen.
Proventil-HFA Adult: 2 puffs tid-qid prn or 2 Severity of asthma will dictate
Ventolin puffs 5 minutes prior to exercise frequency of administration.
ProAir Monitor use: use preventer
Accuneb DPI 200 mcg/dose Child: 1 capsule q 4–6 hrs prn medication if using >3 times a
Other manufacturers of Albuterol and prior to exercise week.
HFA Adult: 1–2 capsules q 4–6 hrs Not recommended for long-term
prn and prior to exercise treatment.
May double usual dose for
exacerbations
Oral syrup 2 mg/ml ≥2 yrs : 0.1 mg/kg bid
6–12 yrs: 2mg tid
oral tablets 2, 3 & 8 mg 6–12 yrs: 2mg tid to qid.
inhalation solution 5mg/ml. (0.5%) Child: 0.05 mg/kg (min 1.25 mg
2.5 mg/ml to max 2.5 mg) in 3 cc of saline
1.25 mg/3ml q 4–6 hrs
0.63 mg/3ml Adult: 1.25 mg – 5mg in 3cc of
saline q 4–6 hrs
Epinephrine** MDI or caplets or tablets 0.2 mg Available without prescription.
Bronkaid 0.25 mg Not recommended due to
Primatene 0.3 mg per dose excessive cardiac stimulation.
AsthmaHaler
Asthmanefrin
Medihaler-Epi
Isotherine hydrochloride** Inhalation solution 0.08% 0.1 mg/kg via nebulizer Rarely used
Bronkosol and various 0.143% Max dose: 5 mg
manufacturers 0.167%
0.2% and 1%
Levalbuterol Inhalation solution 0.31 mg/3ml 2–11 yrs : 0.025 mg/kg (min
Xopenex [R-albuterol] 0.63 mg/3ml 0.63 mg to a maximum of 1.25 mg
1.25 mg/3ml q 4–8 hrs
>12 yrs: 0.63–1.24 mg q 4–8 hrs
Adult: 0.63–2.5 mg q 4–8 hrs
MDI 59 mcg/dose Child: >4 yr to adult: 2 puffs q
4–6 hrs
6 Medications Used in Asthma Management
Metaproterenol sulfate Oral syrup or tablet 2mg/ml < 2 yrs : 0.4 mg/dose tid to qid May cause more irritability than
Alupent 10mg & 20mg 2–6 yrs: 1.3–2.6 mg/kg/day ÷ q other preparations
6–8 hrs
6–9 yrs: 10mg/dose tid to qid
>9 yrs: 20 mg/dose tid to qid
MDI 0.65 mg/ dose 2–3 puffs q 3–4 hr. Max 12
puffs/day
inhalation solution 0.4%, 0.5% and 5% 0.01 – 0.02 ml/kg (max: 15 mg/
dose) q 4–6 hours
Pirbuterol MDI or Breath activated MDI 200 mcg >12 yrs: 1–2 puffs q 4–6 hours to
Maxair a total of 12 puffs
Terbutaline sulfate Oral tablets 2.5 mg, 5 mg <12 yrs: 0.05 mg/kg/dose tid Tablets rarely used
Brethine and other manufacturers increase to 0.15mg/kg/dose
Max daily dose: 5 mg
MDI 200 mcg Max daily dose: 12–15 yr: 7.5mg Monitor use: use prophylactic
6.7 Immunotherapy in Asthma (“Allergy Shots”)
>15 yr: 15 mg drug if using >3 times a week

Injectable (SC) 1 mg/ml 0.25 mg/dose may be repeated in
15–30 min.
Max: 0.5 mg/dose within 4 hr
Beta-agonsits (Long-Acting) (LABA)
Albuterol Oral tablets 4 mg, 8 mg Child: > 6 yrs: 4 mg q 12 hrs Not to be used for symptomatic
Vospire >12 yrs: 8 mg q 12 hrs relief or in place of anti-
Adult: 8 mg q 12 hrs inflammatory therapy
Formoterol fumarate Inhalation capsule 12 mcg/cap Child: < 12 yrs: 1 cap q 12 hrs Can be used for symptomatic
Foradil >12 yrs: 1 cap q 12 hrs relief
Adult: 1 cap q 12 hrs
Salmerterol xinafoate MDI 21 mcg/puff Child: < 12 yrs: 1–2 puffs q 12 Not to be used for symptomatic
Serevent hrs relief or in place of anti-
>12 yrs: 2 puffs q 12 hrs inflammatory therapy
Diskus 50 mcg/blister Child: 1 blister q 12 hrs
Adult: 1 blister q 12 hrs
(continued)
199
200

Anti-inflammatory steroid (inhaled)
Beclomethasone diproprionate MDI 43 mcg/dose Low daily dose Always use with a spacer device
Vanceril, Beclovent and other 84 mcg/dose Child: 84–336 mcg
manufactuers DPI 42 mcg, 84 mcg Adult: 168–504 mcg
Medium daily dose
Child: 336–672 mcg
Adult: 504–840 mcg
High daily dose
Child: > 672 mcg
Adult: > 840 mcg
Beclomethasone diproprionate MDI 40 mcg 4–11 yrs: 1–2 puffs bid
Qvar 80 mcg >12 yrs: 1–2 puffs bid of 40 or
80 mcg
Budesonide Respules 0.25 mg/2ml 1–8 yrs: 0.5 mg to 1 mg qd
Pulmicort Flexhaler and Generic 0.5 mg/2ml or in divided doses
1 mg/2ml
DPI 90 mcg Child 6–17 yrs: 180 mcg bid.
180 mcg Max not to exceed 360 mcg
bid
Adult: ≥18 yrs: 360 mcg bid
Max not to exceed 720 mcg bid
Ciclesonide MDI 80 mcg ≥12 yrs:
Alvesco 160 mcg Low dose: 80 mcg bid
High dose: 160 mcg bid
Max not to exceed 320 mcg bid
Fluticasone furoate DPI 50 mcg ≥5 yrs 50 mcg 1 qd
Arnuity Ellipta 100 mcg ≥12 yrs 100 or 200 mcg 1 qd
200 mcg
Fluticasone propionate MDI 44 mcg Low daily dose May replace beclomethasone or
Flovent 110 mcg Child > 4 yrs: 88–176 mcg budesonide at half the MDI dose
220 mcg Adult: 88–264 mcg
Medium daily dose
Child: 176–440 mcg
Adult: 264–600 mcg
High daily dose
Child: >440 mcg
Adult: >660 mcg
DPI 50, 100 and 250 mcg 1–2 puffs bid

Mometasone DPI 110 mcg Child 4–11 yrs 1 qd in the
Asmanex evening
Twisthaler 220 mcg ≥12 yrs: 220–880 mcg
Mometasone furoate MDI 100 mcg ≥12 yrs: 2 puffs bid
Asmanex 200 mcg Low dose: 200 mcg/day
Medium dose: 400 mcg/day
High dose: 400 mcg bid
Oral Corticostroids
Dexamethasone Oral tablets 0.25 mg, 0.5 mg, 0.75 mg, 0.5–2 mg/kg/day divided q 6 h
Decadron and various generic 1.5 mg, 2 mg & 6 mg
manufacturers Oral solution 0.1 mg/ml and 1 mg/ml
Prednisolone Oral solution 5 mg/5cc Child: 0.25–2mg/kg daily in Pleasant taste
Prelone, Orapred, and various 15 mg/5cc single dose. If needed long term
manufacturers 5 mg use every other day and adjust
Prednisone Oral solution 5 mg/cc other controller therapy
Deltasone and various 5 mg/5cc Short burst: 1–2 mg/kg/day up to

manufacturers Oral tablets 1, 2.5, 5, 10, and 50 mg 60 mg/day maximum for 3–10
days
Adult: 7.5–60 mg in single dose
or every other day for control
Short burst: 40–60 mg/day as
single or 2 divided doses for
3–10 days
Methylprednisolone Oral tablet 2, 4, 8, 16, and 32 mg Child: 7.5 mg/kg IM once Useful in those who are vomiting
Medrol and various Repository injection 40 mg/ml Adult: 240 mg IM once and in place of oral steroids
manufacturers 80 mg/ml
Triamcinolone Oral tablet 1 mg, 2mg, 4 mg, and 8 mg Also available as a syrup
Aristocort and various
manufacturers
Leukotriene receptor antagonists (LTRA)
Montelukast sodium Oral tablets 4 and 5 mg chew tabs and 10 mg 2–5 yrs: 4 mg/day Also use in the treatment of
Singulair tablet 6–14 yrs: 5 mg/day rhinitis. Doses >10 mg will not
>14 yrs: 10 mg/day produce greater response in
Adult: 10 mg/day adults
(continued)
201
202

Zafirlukast Oral tablets 10 mg and 20 mg 7–11 yrs: 10 mg bid Take 1 hour before or 2 hours
Accolate > 12 yrs: 20 mg bid after meals
Adult: 20 mg bid
Zileuton Oral tablets 300 mg and 600 mg > 12 yrs: 600 mg qid with meals Hepatic enzymes must be
Zyflo monitored
Long-acting muscarinic antagonists (LAMAS)
Tiotropium MDI 1.25 mg Child > 6 yrs 2 puffs qd
Spiriva Respimat 2.5 mg Adult: 2 puffs qd
Anti-cholinergics
Ipratopium bromide MDI 0.018 mg/dose 3–12 yrs: 1–2 puffs tid. Max 6
Atrovent puff/day
> 12 yrs: 2 puffs qid. Max 12
puffs/day
Inhalation solution 200 mcg/ml Infants or children: 250–500 Protect eyes from exposure when
mcg tid or qid using inhalation solution
> 12 yrs: 250 mcg 3–4 times
daily
Xanthines (Bronchodilators)
Aminophyline Oral tablets 100 mg, 200 mg See theophylline dosing 100 mg
Various manufacturers Oral solution 21 mg/ml (consider mg of theophylline aminophyline = 80 mg
Rectal suppositories 250 mg, 500 mg available) theophylline
Theophylline Oral liquid 5.33 mg/ml Child: start with 10 mg/kg/day Serum monitoring required so
Oral tablet 300 mg Usual maximum that 5–15 mcg/ml is maintained
Oral extended release capsules 100, 200, 300 and 450 mg < 1 yr: 0.2 × (age in weeks) + 5
and tablets = mg/kg/day
Theo-24 Oral extended release capsules 100, 200, 300 and 400 mg > 1 yr: 16 mg/kg/day
Uniphyl 400, 600 mg Adult: start with 10 mg/kg/day
up to 300 mg max
Usual maximum: 800mg/day
Anti-allergic agents
Cromolyn Oral tablets 1 mg 6m–3yr: 0.05mg/kg/dose bid Initial sedation common. Can be
Intal and various manufacturers >3 yr: 1mg bid used prior to exercise
Oral syrup 0.2 mg/ml hild: 1–2 puffs (2 mg) tid or qid Inconvenient. May be reduced to
MDI 1 mg/puff Adult: 2–4 puffs tid or qid tid or bid
Inhalation solution 10 mg/ml 20 mg (one ampoule of 2 ml) tid
(2 ml) or qid
Combination products
Advair MDI 45 mcg F/21 mcg S Child and adult: 1 inhalation bid Rinse mouth after inhalation
Salmeterol/Fluticasone 45 mcg 115 mcg F/21 mcg S with dose depending on the after any ICS
115 mcg 230 mcg F/21 mcg S severity of asthma
230 mcg
Diskus 250 mcg 250 mcg F/50 mcg S
Wixela Inhub DPI 100 mcg F/50 mcg S ≥ 4 yrs: 1 inhalation bid
Salmeterol/Fluticasone 250 mcg F/50 mcg S
500 mcg F/50 mcg S
AirDuo Digihaler DPI 113 mg F/14 mcg S ≥ 12 yrs: 1 inhalation qd
Salmeterol/fluticasone
Symbicort 80 mcg 80 mcg B/4.5 mcg F 1 inhalation qd
Budesonide/formoterol 160 mcg 160 mcg B/4.5 mcg F
Breo Ellipta 100 mcg 100 mcg F/25 mcg V ≥ 18 yrs: 1 inhalation qd Rinse mouth after inhalation
Fluticasone/vilanterol 200 mcg 200 mcg F/25 mcg V
Dulera 100 mcg 100 mcg M/5 mcg F ≥ 12 yrs: 1 inhalation qd

Mometasone/formoterol 200 mcg 200 mcg M/5 mcg F
Trelegy Ellipta 100 mcg 100 mcg F/62.5 mcg U/25 mcg V ≥ 18 yrs: 1 inhalation qd
Fluticasone/umeclidinium/ 200 mcg 200 mcg F/62.5 mcg U/25 mcg V
vilanterol
Immunomodulators
Benralizumab Fasenra Injection 30 mg/ml ≥12 yrs: q 4 weeks for first 3 Pre-filled syringes, pre-filled pen
doses then q 8 weeks
Dupilumab Dupixent Injection 200 mg/1.4 ml 300 mg/2ml ≥12 yrs: q 2 weeks Pre-filled syringes, pre-filled pen
Mepolizumab Nucala Injection 100 mg/ml ≥12 yrs: 100 mg q 4 weeks Autoinjector
Omalizumab Xolair Injection 75 mg/0.5 ml 150/ml ≥6 yrs: 75–375 mg q 2–4 weeks Pre-filled syringes, pre-filled pen
Reslizumab Cinquair Injection 100 mg/10 ml ≥18 yrs: 3 mg/kg q 4 weeks Intravenous infusion over 20–50
minutes
Abbreviations MDI metered dose inhaler, DPI dry powder inhaler
**Not listed by the NAEPP Guidelines
References
Taketamo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook 7th ed. 2000-2001, Lexi-Comp Inc. Hudson Ohio. 2000. Electronic Orange Book, Approved Drug Products
with Therapeutic Equivalence, http://www.fda.gov/cder/ob/default.htm. American Hospital Formulary System (AHFS) Drug Information 2001. American Society of Health
System pharmacists. The Allergy Report. Diseases of the Atopic Diatheses, Volume 2. American Academy of Allergy Asthma & Immunology, 2000. The American Academy of
Allergy Asthma & Immunology website at https://www.aaaai.org/conditions-and-treatments/drug-guide
203
Table 6.5 Asthma medications, side effects, and time to onset of activity
Medications Common side effects and precautions Time to take effect
Relievers
Albuterol Mild tremor 1 to 15 minutes
Fenoterol Slight increase in heart rate
Isoetharine Hyperactivity
Levalbuterol Occasional leg cramps
Metaproterenol No advantage to adding another one from the same group
Terbutaline
Pirbuterol
Ipratropium Dry mouth 30 to 40 minutes
Unpleasant taste in mouth
Theophylline Hyperactivity, abdominal pain, vomiting, headache, increase 4 to 8 hours
products in heart rate
Take with food. Blood level must be monitored regularly
Long-acting relievers—used as controllers and always with inhaled corticosteroids
Salmeterol Headache, tremor, dizziness, nausea, anxiety, vomiting Salmeterol: some effect in
Formoterol Increase in heart rate 30 mins; 4 hours for
Long-acting bronchodilator maximum effectiveness
Maximum use: 2 times a day Formoterol: some effect in
Salmeterol cannot be used for symptomatic relief 1–3 mins; 30 mins to
maximum effectiveness
Albuterol sulfate Nervousness, headache, dizziness, trouble sleeping, nausea, 7 hrs to maximum
muscle cramps effectiveness
May raise blood pressure
Extended-release tablets should not be crushed, chewed, or
split. Swallow whole
Inhaled corticosteroids
Beclomethasone May cause hoarseness or oral thrush 3 to 7 days
Budesonide Rinse mouth after inhalation
Ciclesonide Very effective in preventing asthma
Flunisolide Systemic effects possible at high doses
Fluticasone furoate
Fluticasone
propionate
Mometasone furoate
Oral corticosteroids
Prednisone Few side effects if used for short term 4 to 6 hours
Prednisolone May increase appetite
Dexamethasone May cause mood changes
Methylprednisolone Special precautions required
Leukotriene inhibitors
Zafirlukast May cause headache, dizziness, infection, nausea, diarrhea, 3 hours
Montelukast vomiting. Cannot be used for symptomatic relief
Cannot be used for symptomatic relief
Zileuton Must be swallowed whole without chewing. Must be taken 1
hour before or 2 hours after meals.
Long-acting muscarinic antagonist
Tiotropium May cause dry mouth, constipation, stomach pain, vomiting, 3 hours
indigestion, muscle pain, nosebleed, runny nose, sneezing,
painful white patches in mouth. Do not swallow capsules. Do
not get powder from capsules in eyes
• Have relevant confirmatory testing proving conditional recommendation that SCIT be con-
sensitization (as above) sidered by individuals who place:
• Test positive because of rhinitis, for example,
and not asthma • A high value on small improvements in qual-
• Are aware of the risks, including that of severe ity of life and symptom control
systemic reactions • A high value on reductions in long-term and/
or quick-relief medication use
It is important that control be optimized in the • A lower value on the potential for systemic
all the ways detailed earlier in this book. Having reactions of wide-ranging severity
said that, SCIT should not be used in severe
asthma. The SCIT dose should not be changed Additional cautions included the small sample
when there are asthma symptoms. Both the pre- size of studies and a lack of reference to race or
scriber and the person with asthma must recognize social determinants of the health of those studied.
the heterogeneous nature of asthma triggers. There The conclusion was: “Whether to use SCIT
may be allergic triggers, but other triggers may be should be a shared decision between the individ-
more relevant in many people with asthma, includ- ual and the healthcare provider, and this decision
ing viral illness, irritants, and exercise. should consider the individual’s asthma severity
SCIT should never be administered at home— and willingness to accept the potential harms
“personnel with appropriate training should pre- related to SCIT. Clinicians should administer
pare and administer injections for each individual’s SCIT in a clinical setting that has the capacity to
dosing schedule, from the build-up to the mainte- monitor and treat reactions.”
nance phase.” Reactions “can include a range of In terms of sublingual immunotherapy (SLIT),
anaphylactic symptoms involving the skin (urti- the FDA has approved SLIT tablets, but not aque-
caria), respiratory tract (rhinitis and asthma), gas- ous preparations, for allergic rhinoconjunctivitis.
trointestinal tract (nausea, diarrhea, and vomiting), People with this condition together with asthma
and the cardiovascular system (hypotension and may derive benefit. However, the Expert Panel
arrhythmias). Although rare, deaths after injec- recommends against the use of SLIT in the treat-
tions have been reported.” (See “Anaphylaxis” in ment of asthma.
Chap. 9.) Hence, SCIT should be carefully super- Given the many questions, and lack of strong
vised, and resuscitative equipment should be evidence, it is not surprising that “the Expert
readily available. Some reactions may occur more Panel identified the following opportunities for
than 30 minutes after injection, so the individual additional research:
must carry an epinephrine injector and ensure that
it has not reached its expiry date. • Investigate the safety and efficacy of immuno-
Overall, the evidence reviewed by the panel therapy in individuals with severe asthma,
provides only moderate or low certainty of bene- particularly those whose asthma is under con-
fit to people with asthma [38]. Studies were trol but who want to reduce their medication
mainly of persons with mild and moderate burden
asthma. They included people with varying • Include only children ages 5–11 years in stud-
degrees of control, and often the degree of con- ies of children, or, if a study includes a broader
trol was not stated. There was low certainty of age group, report findings separately for chil-
evidence for critical outcomes such as reduction dren ages 5–11 years and those 12 years and
in exacerbations, improvement in quality of life, older
and asthma control. • Study more diverse populations to determine
SCIT may reduce SABA use and allow doses whether race or ethnicity influences the effi-
of long-term controllers to be reduced. Quality of cacy and safety of immunotherapy
life may be improved in those with troublesome • Study the efficacy and safety of multiple-
rhinitis or conjunctivitis. The Expert Panel gave a allergen SCIT or SLIT regimens to assess
compliance, adherence, and the effect of these acquired notoriety in the COVID pandemic
factors on asthma management despite a lack of supportive evidence [91].
• Standardize methods to report SCIT and SLIT Their use belongs to a previous era of asthma
doses used in studies and use validated out- management, when there were few alternatives to
come measurement instruments, such as OCS for severe asthma. HCPs sought desperately
asthma symptoms and adverse events.” to identify medications already in use for other
conditions that might have an effect in asthma.
The evidence for benefit in asthma was always
6.8 Low Evidence-Based tenuous, and where Cochrane reviews were done,
Medications as Treatment strong recommendations never emerged. If any-
Options one with asthma is still receiving one of these
preparations, the educator should provide the
The unusual title of this section requires some person with full information on current
explanation. Some authors have used the term approaches to asthma and encourage transition to
“alternative” to describe the use, in asthma, of a modern regimen.
approved medication that was not originally
intended for asthma [88, 89]. In this book, “alter-
native” has a different but more widespread 6.9 Role of Bronchial
meaning—it refers to “complementary/alterna- Thermoplasty in Treatment
tive” treatments that are not usually used by con-
ventional healthcare practitioners. While Bronchial thermoplasty (BT) is used in some
alternative treatments are described in Chap. 12, centers as an adjunct therapy. Smooth muscle is
it is worth noting that the evidence in favor of the increased in the airways of those with asthma,
add-on treatments described here is weak, some- and this muscle thickening may persist even with
thing that they share with the evidence in favor of appropriate conventional therapy. BT is radiofre-
many of the treatments described in Chap. 12. quency energy provided with proprietary equip-
ment, via probes, to the airway wall. This
controlled heating of the airway wall eventually
6.8.1 A
pproach to the Use of These reduces the muscle mass.
Medications Some early studies have been promising. For
example, Cox et al. studied 16 subjects, all with
These medications include troleandomycin mild to moderate asthma [92]. Before any treat-
(a macrolide antibiotic), cyclosporine, metho- ment was given, the subjects were assessed using
trexate, gold, intravenous immunoglobulin, dap- spirometry, peak flow diaries, monitoring of
sone, hydroxychloroquine, and colchicine. In symptoms, and their use of medication. The same
general, they have proved disappointing. They measurements were made at 12 weeks, 1 year,
either have no effect, or when they do, the effect and 2 years after the treatment. The treatment
is small together with the potential to cause seri- itself was delivered via bronchoscopy with a
ous side effects. There is some readily available probe directed toward the airway wall, as far as
but limited evidence for the use of intravenous could be reached with the bronchoscope. There
gamma globulin. The only medication mentioned was no comparison group nor sham (i.e., pla-
in current guidelines is a macrolide antibiotic, but cebo) group. The main conclusion of the study
the one used previously, troleandomycin, is listed was that it was well tolerated and that they dem-
as discontinued on the FDA’s website [90]. If a onstrated decreased airway hyperresponsiveness
macrolide is needed in the very limited way that persisted for the 2 years of the study.
described in current guidelines, a number are By contrast, Castro and coworkers used a ran-
available including azithromycin. The list domized, double-blind, sham-controlled clinical
includes hydroxychloroquine, a medication that trial [93], with 30 trial sites in 6 countries. Those
6.10 Concern About Side Effects: General Approach 207
studied were adults, 18–65 years of age and with Overall, asthma medications are safe, with a
a confirmed diagnosis of asthma and high-dose low (but not zero) incidence of side effects. Most
ICS, usually with a long-acting beta-2 agonist. recent developments in asthma therapy have been
Many of them were on other medications such as directed toward finding safe alternatives to
leukotriene modifiers, omalizumab, and oral cor- OCS. Nevertheless, a survey of 1,230 children
ticosteroids. 580 individuals were screened, with and 604 adults with asthma found that side effects
297 randomized to the BT group and 101 to the of medications and quality-of-life issues were of
sham control group. All subjects underwent three great concern [94]. More than half (56–58%) of
bronchoscopy procedures, 3 weeks apart. In the the children or their parents, and 42 to 64% of
active group, the radiofrequency treatment was adults, complained of the side effects of broncho-
delivered to the airway using commercial equip- dilator therapy. These included tachycardia
ment. In the sham group, the catheter for the (64%), jitteriness (60%), shaky hands (43%), and
equipment was introduced into the airway, and a restlessness (42%). The study also revealed that
sham controller with flashing lights was used. healthcare providers tended to adjust bronchodi-
Asthma quality-of-life scores (AQLQ) were used lator therapy for adults more than for children. A
to assess the impact of the therapy and were further disturbing statistic was that only 3% of
higher with thermoplasty compared to sham those using MDIs (79% of children and 72% of
treatment. There was also a reduction in severe adults) viewed their healthcare providers as “car-
exacerbations, and in healthcare use, after ing, sympathetic, willing to listen or willing to
treatment. discuss the problem.” As a result, in an attempt to
The 2020 NHLBI Update [2] is clearly unen- alleviate the side effects, 25 to 30% of them
thusiastic about thermoplasty. It describes reduced either the dose or frequency of their
“small” harms and “moderate” benefits, with a bronchodilator medications without consulting
paucity of information on long-term outcomes. their healthcare providers.
Thus, the report strongly encourages research Full information should always be provided
using randomization and also long-term regis- about:
tries. If thermoplasty is to be used, it should be
supervised by a physician experienced in its use • The medication that has been given
and following a consent process that is detailed • The reason why it was given
and truthful about potential risks and poor evi- • The time it will require before any effect may
dence of benefit. be noticed (about a week for ICS)
• How and when it should be taken
6.10 C
oncern About Side Effects: The above list must include a description of
General Approach potential side effects and action to be taken when
the person with asthma suspects side effects. The
Side effects are real, and concern about them is specific manner in which potential side effects
based in reality. Medications used in asthma may are described is very important and will be
cause side effects, and most are listed earlier in detailed later. The importance of dealing effec-
this chapter. Many people using asthma medica- tively with side effects lies not only on the harm
tions will be familiar with the history of other they might cause but also on the harm misattribu-
medications and delayed recognition of their side tion of side effects or misunderstanding of bene-
effects in such substances as thalidomide, chlor- fits might cause. For example, many people with
amphenicol, and cisapride. Similarly, hormone asthma have become used to the immediate
replacement therapy for women after menopause effects of bronchodilators and when given ICS
was once enthusiastically prescribed, then pro- expect similar immediate relief. They then
scribed, and is now used cautiously in some spe- become annoyed and upset when it is not forth-
cial situations. coming. This encourages them to reduce or stop
the medication. Unpleasant symptoms attributed fites, are known to cause bronchoconstriction and
to side effects, whether or not they are side trigger asthma [99].
effects, will also lead to reluctance to medicate. Most pharmaceutical companies offer a toll-free
Perception of side effects does not necessarily consumer information phone number (available
equate to their reality. There is already a “large from any pharmacy or on package inserts). Persons
reservoir of bodily symptoms available for misat- with asthma or their caregivers should call these
tribution by the patient to the medication” [95]. numbers if they have any concerns and should
Also, new symptoms may be the somatic accom- check not only prescription items but also over-the-
paniments of anxiety, depression, or stress. Any counter (OTC) products that they purchase.
chronic condition, and asthma is no exception, Studies have found that asthma medica-
may be accompanied by psychological conse- tions, particularly in children, result in tooth
quences. Symptoms of mild infirmities or self- erosion [100–102]. Long-term use of asthma
limited ailments, such as headaches, cramps, or medication was also associated with tooth
extra symptoms, may be attributed to a new, or wear in American adolescents and young
even an existing, medication. Perception of nor- adults [103]. Another study by McDerra,
mal functioning, such as dizziness when rising Pollard, and Curzon [104] in the UK also
too quickly, may also be labeled a medication found a potential dental problem with pow-
side effect. It should be remembered that approx- dered asthma medications. Tooth substance
imately one quarter of patients taking a placebo begins to dissolve at a pH of 5.5. Since most
report adverse side effects [96]! asthma medications have a pH less than 5.5,
In addition to the issue discussed above, it is children should be advised to:
important to remember that potential adverse reac-
tions to inhaled medications may actually be due • Rinse their mouths with water directly after
to problems with the non-medicinal compo- taking asthma medications
nents—the propellants, preservatives, and surfac- • Use a spacer device
tants. Many DPIs use lactose as a filler. MDIs may • Brush their teeth twice a day
use ethylenediaminetetraacetic acid (EDTA),
metabisulfite, or benzalkonium chloride as preser- The knowledge that misattribution of side
vatives. For some people, these compounds induce effects is more likely in those who expect side
bronchospasm and bronchoconstriction [97]. effects or have coexistent psychological condi-
Many pharmaceutical preparations contain a tions or psychosocial stressors will help suggest
variety of excipients. These are generally inac- an approach to the discussion. The precise nature
tive, but persons with allergies need to be aware of how information about potential side effects is
of their presence. Lactose is a common excipient, given is dependent on one’s personal style.
but others that may cause allergic reactions However, in general, consider the following:
include sweeteners, flavorings, dyes, and preser-
vatives. Most package inserts often do not iden- • The medication should be related to disease
tify the flavorings. In those who are severity:
lactose-intolerant, lactose in medications has • Systemic corticosteroids have no place in
been known to cause diarrhea, malabsorption, mild asthma, but if they have been found
flatulence, and vomiting. Saccharin has been necessary in severe asthma, and there is
associated with wheezing, tachycardia, urticaria, concern about side effects, then any
pruritus, nausea, and diarrhea. For sorbitol, the planned discontinuation should happen
adverse effects include poor absorption of the gradually under professional supervision
active drug, flatulence, osmotic diarrhea, and with simultaneous substitution of alterna-
abdominal pain. The preservative ethylenedi- tive anti-asthma medications.
amine can irritate both skin and mucous mem- • Potential side effects should be discussed, and
branes [98]. Dyes such as FD&C Blue 1, information provided about their likely fre-
Tartrazine, FD&C 4, and carmine, as well as sul- quency, if known.
6.11 Classification of Severity After Treatment 209
• The professional monitoring that will be done may be that appropriate treatment has not been
(with respect to side effects) should be prescribed or followed, or that the diagnosis of
explained. asthma is wrong, or that the asthma is very severe
• Reassurance should be provided that all medi- [1, 105–107].
cations, and their doses, have been well justi- Classification of control and severity should
fied and will be reviewed at every be done both before and after treatment [108], but
assessment. will change after treatment. Classification before
treatment was described in Chap. 4 (Tables 4.2
When concern about side effects is expressed, and 4.3), while classification after treatment is
the educator or HCP must take that concern seri- shown in Figs. 6.1, 6.2, and 6.3.
ously, and all possibilities explored and an agreed If the asthma is intermittent, use of a short-
course of action mapped out. acting beta-agonist more than twice a week may
be indicative of a need for daily long-term control
therapy. People with intermittent asthma may
6.11 Classification of Severity require regular low-dose ICS. In effect, their
After Treatment asthma can be classified as mild persistent.
Intermittent asthma can be effectively and safely
Asthma control and asthma severity should not managed with short courses of ICS during exac-
be confused—the two are different concepts, erbations and without them during symptom-free
although severe asthma will often prove difficult intervals. If the asthma can be controlled with a
to control. Nevertheless, the perception that low to medium dose of inhaled corticosteroids
poorly controlled asthma is synonymous with with or without other controller medications
severe persistent asthma is incorrect. Control has (such as long-acting beta-agonists), it is consid-
more immediate importance and is normally ered moderate persistent. As soon as high-dose
achievable. When good control is not achieved, it ICS with a LABA are required (and even OCS),
Fig. 6.1 Step-wise approach to therapy (0–4 yrs) (© The Asthma Education Clinic Ltd.)
Fig. 6.2 Step-wise approach to therapy (5–11 yrs) (© The Asthma Education Clinic Ltd.)
Fig. 6.3 Step-wise approach to therapy (12 yrs and older) (© The Asthma Education Clinic Ltd.)
the asthma is considered severe persistent. In hand, severe asthma may become moderate or
effect, once control of asthma has been estab- even mild with the appropriate treatment. Hence,
lished, it is the medication requirement that the healthcare provider or asthma educator should
reflects the degree of severity [35, 107]. Severity periodically classify (or re-classify) each individ-
in that sense is based on the minimum medication ual’s degree of control and asthma severity.
needed to maintain control.
Asthma control is currently achieved through
one of the two approaches: 6.12 S
tep Approach to Asthma
Management
• The first starts the therapy at the level appro-
priate to the assessed severity by using the The 2007 guidelines [35] suggest that once a diag-
classification system to determine the initial nosis has been made, two factors must be taken into
amount of medication that should be pre- account when reviewing a person’s asthma—sever-
scribed. If control is not achieved, medication ity and control. Control will determine initial ther-
is then stepped up to the next higher level apy and whether treatment needs to be stepped up
where the dosage of ICS is increased, and add- over time or can be reduced. Control must be evalu-
on therapy possibly commenced. ated at all visits. Severity may be clear at the initial
• The second approach starts one level higher visit. As an example, someone may come for evalu-
than indicated by the degree of severity, brings ation having previously been on low-dose ICS and
the disease under control, and then reduces the was admitted to an ICU with asthma. This is severe
medication to the minimum needed while asthma. Someone else may come for assessment
monitoring the asthma to ensure that it remains with a history of 2–3 days’ symptoms with colds,
under control. easily relieved with SABA and with normal spirom-
etry. This person has mild asthma. The true severity
Once the asthma is well controlled, consider- may only become clear over time. Based on symp-
ation can be given to stepping down or reducing toms and moderately abnormal spirometry, a mod-
the dosage of ICS. Current guidelines [2, 35] sug- erate ICS dose may be prescribed. If there is a poor
gest reducing the dose by about 25% every 2 to 3 response, a higher-dose ICS along with LABA will
months as long as asthma control is appropriate. be used. If symptoms and abnormal spirometry per-
The time period is important, since too rapid a sist, this is severe asthma, and consideration should
step-down may lead to sharp deterioration in be given to use of a biologic. As always, as men-
symptoms. The step-down approach begins with tioned repeatedly in this book, when there is an
an initial reduction in the dose of ICS. If the apparent poor response, a full reassessment is
asthma remains under control, then the ICS are needed before reaching a conclusion about severity
reduced further, perhaps adding a long-acting or about changing treatment. The assessment as
bronchodilator. Again, if asthma control is main- always will include confirmation that:
tained for about 3 months, then the dose of ICS
may be further reduced. • The diagnosis of asthma is correct
The classification of severity gives the health- • There are no significant comorbidities
care provider a starting point for prescribing ICS • There are no financial barriers to accessing
and add-on therapy until the asthma is well con- therapy
trolled. It also provides the basis for written • Inhaler technique is perfect
Asthma Action Plans (AAP) and permits the • Adherence to a treatment schedule is
reduction of ICS on the premise that the asthma near-perfect
remains well controlled. • Triggers are avoided, wherever possible
Whatever the classification, it should be noted
that asthma severity is a continuum. Mild or mod- At all visits, including the initial visit, asthma
erate asthma may become severe; on the other severity is ascertained using the domains of cur-
rent impairment and future risk. Impairment is Predictors of attacks for all ages include:
evaluated according to:
• Psychosocial factors—depression, increased
• Frequency of symptoms stress, socioeconomic factors
• Nocturnal awakenings • Familial attitudes and beliefs about taking
• Frequency usage of short-acting medications
beta-agonists • Demographic characteristics—female, non-
• Level of interference with normal activities white, current smoking, non-use of ICS
• Work/school days missed • A feeling of being fearful or in danger
• Quality-of-life assessments
• Pulmonary function For children aged 4 and under, the risk factors
for persistent asthma also include [35]:
Because it is generally difficult to measure Any one of the following:
pulmonary function in children under the age of
5, pulmonary function tests done through spi- • Parental history of asthma
rometry are part of both diagnosis and assess- • A diagnosis of atopic dermatitis
ment of severity for every one over this age. • Evidence of sensitization to aeroallergens
(Peak flow meters, while adequate for monitor-
ing asthma, are not sufficiently reliable to aid in And any two of the following:
the classification of severity or degree of
control.) • Evidence of food sensitization
Measures of lung function to be determined • >4% peripheral blood eosinophils
by spirometry include: • Wheezing apart from colds
• FEV1—forced expiratory volume in one Risk in those aged 5 and above is ascertained
second by the frequency of attacks. Two or more attacks
• FVC—forced vital capacity a year automatically put them into the persistent
• FEV1/FVC—the ratio of the two measures asthma category.
• FEV6—forced expiratory volume in 6 Once the diagnosis is made and asthma sever-
seconds ity classified, an aggressive approach toward con-
trol is taken. The classification of severity is
The role of this last measure (FEV6) in assess- connected to the six-step approach recommended
ing pulmonary function has recently been by the Expert Panel Report 3 (EPR 3) Guidelines
reviewed [109]. It has been suggested that it be [35] for three distinct age groups: 0–4, 5–11, and
used instead of the FEV1/FVC ratio as FVC does 12 years and older with:
not need to be measured.
Risk pertains to the number of asthma exacer- • Intermittent asthma considered a Step 1
bations or wheezing episodes that have occurred. category
Frequency and intensity of attacks are also fac- • Mild persistent asthma a Step 2 category
tors and would include: • Moderate persistent asthma rated at the Step 3
and Step 4 categories
• Two or more emergency visits in the past • Severe persistent asthma rated at the Step 5
year and Step 6 categories
• Any history of intubation or ICU admission
within the last 5 years The initial treatment corresponds with the
• Severe airflow obstruction, as determined by appropriate step therapy and should be such that
spirometry the asthma is quickly brought under control. This
• Persistent severe airflow obstruction may require oral corticosteroids to reduce the
inflammation in the airways and to remind them LAMA is suggested only for the 12 years and
of how well they can be, a feeling too often for- older group, while LTRA are alternate choices
gotten if they have adjusted to the symptoms of for both the 5–11 and older age groups.
asthma and modified their lifestyle to handle the Montelukast is a suggested alternate choice only
limitations imposed by the asthma. for the 0–4 age group. All groups, of all ages, are
Figures 6.1, 6.2, and 6.3 provide the necessary prescribed a SABA.
information for both stepping up and stepping It should be noted that immunotherapy may be
down with the recommended alternatives accord- considered for the 5–11 age group with allergic
ing to the 2020 guidelines. asthma, particularly to house dust mite, animal
Note that Steps 1 and 2 are identical for all dander, and pollen. A more detailed review of
three age groups—for individuals with intermit- immunotherapy is in Sect. 6.7.
tent asthma (Step 1), a short-acting beta-agonist Table 6.6 shows a comparison of Steps 3 to 6
can be taken as required, and for those with mild between the different age groups.
persistent asthma (Step 2), a low corticosteroid When assessing control, consider the loss of
dose is recommended. The three following tables lung function. Spirometry is recommended not
provide a comparison of Steps 3 to 6 (moderate to only at the initial visit to confirm a diagnosis of
severe persistent asthma) for different age groups. asthma but also after treatment has been initiated
Regular use of oral corticosteroids (OCS) is added and both symptoms and peak flow readings have
to the medication regime only at Step 6, indicative stabilized. Spirometry should also be done during
of difficult-to-control severe persistent asthma. periods of progressive or prolonged loss of control.
Note that the preferred first choice of a LABA The EPR 3 Guidelines [35] recommend spirometry
for Steps 3, 4, and 5, for the 5–11 and 12 yrs and every 1 to 2 years for everyone who has asthma.
older age groups, is formoterol. This is in keep- The following three levels of control, well
ing with the SMART (single maintenance and controlled, not well controlled, and very poorly
reliever therapy) approach since formoterol, a controlled, can be used in anyone with asthma.
LABA which can be used as a reliever, is avail- The guidelines use three age groups—0 to 4
able in combination with the ICS budesonide in a years, 5–11 years, and those 12 and over.
single device. Assessment of control is shown in the following
Table 6.6 Age-related comparison of Step 3 to Step 6

0–4 years 5–11 years 12 years and over
Step 3
ICS low dose + ICS low dose + formoterol ICS low dose + formoterol
LABA or montelukast Or medium-dose ICS Or ICS low dose + LABA/LAMA/
Or medium-dose ICS Or low-dose ICS + LABA/LTRA LTRA
Or low-dose ICS + theophylline Or ICS low dose + theophylline
Or ICS low dose + zileuton
Step 4
ICS medium dose + LABA ICS medium dose + formoterol ICS medium dose + formoterol
Or ICS medium dose + Or ICS medium dose + LTRA Or medium-dose ICS + LABA/LAMA
montelukast Or ICS medium dose + theophylline Or medium-dose ICS + LTRA
Step 5
ICS high dose + LABA ICS high dose + formoterol ICS high dose+ formoterol
Or ICS high dose + montelukast Or ICS high dose + LTRA Or medium-dose ICS-LABA
Or ICS high dose + theophylline Or high-dose ICS + LTRA
Step 6
ICS high dose + LABA + OCS ICS high dose + LABA + OCS ICS high dose+ LABA + OCS
Or ICS high dose + montelukast + Or ICS high dose + LTRA + OCS Consider biologics
OCS Or ICS high dose + theophylline +
OCS
ICS inhaled corticosteroid, OCS oral corticosteroid, LABA long-acting bronchodilator, LTRA leukotriene receptor
antagonist. SABA prn for all categories and all age groups
Table 6.7 Level of control for ages 0–4 years

Level of control 0–4 years
Impairment components Controlled Poor control Very poor control
Symptoms ≤ 2 days/week > 2 days/week Throughout the day
Night awakenings 1/month > 1/month > 1/week
SABA use ≤ 2 days/week > 2 days/week Several times/day
Interference with normal activities None Some Extremely limited
Risk domain: exacerbations 0–1/year 2–3/year > 3/year
Table 6.8 Level of control for ages 5–11 and for 12 years and older
Level of control 5–11 years and ≥ 12 years
Impairment components Controlled Poor control Very poor control
Symptoms ≤ 2 days/week > 2 days/week Throughout the day
Night awakenings < 1/month > 2/month > 2/month
≥ 12 yrs ≤ 2/month 1–3/week > 4/week
SABA use ≤ 2 days/week > 2 days/week Several times/day
Interference with normal activities None Some Extremely limited
Lung function 5–11 yrs FEV1> 80% FEV1 60–80% FEV1< 60%
FEV1/FVC > 80% FEV1/FVC 75–80% FEV1/FVC < 75%
≥ 12 yrs FEV1 or PEFR > 80% FEV1 or PEFR FEV1 or PEFR < 60%
60–80%
Risk domain: exacerbations 0–1/year ≥ 2/year ≥ 2/year
Table 6.9 Recommended action for treatment depending on level of control

Well controlled Not well controlled Very poorly controlled
• Maintain current regimen • Step up one step • Consider burst of OCS
• Follow-up regularly every 1–6 months • Re-evaluate in 2–6 weeks • Step up 1–2 steps
• If well controlled for 3 months, then step down • Re-evaluate in 2 weeks
two tables, where there is considerable common- can be made to reduce the medications by step-
ality except where the 5–11 age group differs ping down while ensuring that the asthma
from the 12 and older (Tables 6.7 and 6.8). remains under control. As noted earlier, step-
The EPR 3 Guidelines [35] recommend stepping down is best done at infrequent intervals,
ping up or down, depending on the level of con- with careful reassessment 2–3 months after each
trol. See Table 6.9. change.
Again, prior to taking action and stepping up
treatment, the educator should confirm the diag-
nosis and review: 6.13 Goals of Therapy
• Adherence to medication What is the purpose of assessment and treatment

• Inhaler technique of people with asthma? In essence, it is to give
• Environmental control them a good life, with minimal restrictions and
• Avoidance of allergens and irritants minimal or no symptoms using an acceptable
• Comorbid conditions medication regimen without side effects. Such
are the “goals of therapy” in broad terms. Specific
It follows that an assessment of control is goals will be developed jointly between the pre-
necessary at every visit to ensure that the asthma scriber/educator and the person with asthma
is not going out of control. If control is poor, based on individual preferences.
then stepping up should be considered. Once the Assessment of severity is the basis in determin-
asthma is brought under control, then attempts ing goals of therapy. Severity is assessed on two
6.14 Quality-of-Life Scores 215
items—impairment and risk. Hence, measures to study of children with moderate asthma noted five
reduce both impairment and risk are essential. areas that determined their quality of life [112]:
Impairment can be reduced by:
• Physical restrictions due to symptoms
• Preventing chronic symptoms • Limitations on daily activities
• Infrequent symptoms requiring SABA for • Discord in parent-child relationships
relief • Restrictions in school social activities
• Maintaining normal pulmonary function • Daily inconvenience in managing their asthma
• Maintaining normal activity levels
• Defining “normal” may be difficult as low Family members and all caregivers are
activity levels may have become a coping affected by the presence of asthma. This is obvi-
mechanism. ous but often overlooked. For example, 360 care-
• Meeting the expectations of the person who givers of children with uncontrolled asthma and
actually has asthma and their families 113 children with controlled asthma were sur-
• Satisfying both personal and family require- veyed. Not surprisingly, children with uncon-
ments for asthma care trolled asthma had significantly lower QOL than
those with controlled asthma. The caregivers of
Risk can be reduced by: children with uncontrolled asthma also reported a
significantly increased workload, impaired activ-
• Preventing attacks and ED visits ities, and lower QOL. Caregivers of these chil-
• Preventing progressive loss of lung function dren lost more work time and had significantly
• Providing optimal pharmacotherapy with reduced productivity and work impairment.
minimal or no adverse effects Asthma had an impact on emotions, time, and
family activities [113].
The goal is simple: minimum medication and Poorly controlled or uncontrolled asthma has
minimum side effects to achieve asthma control. a deleterious effect on QOL of all parties [114,
The “goal” should be an agreed one. The person 115]. Compared with people who do not have
with asthma must be a full partner in this assess- asthma, people with asthma have a lower QOL
ment process. which is compounded by both asthma severity
and lack of control [116]. There is a link between
QOL scores and pulmonary function [117]. Thus,
6.14 Quality-of-Life Scores QOL questionnaires used in asthma are similar to
those used to determine severity and include
Healthcare professionals (HCP) are concerned questions related to symptoms, exercise-related
about asthma control and in the past have focused symptoms, night-time awakenings, and use of
more on the condition called asthma than on the reliever medication. Some also ask about limita-
individual who has asthma. This was wrong then tions to daily activities.
and remains wrong. Successful treatment must be a The National Standards of Care require the
partnership. The healthcare professional should use of validated QOL scores. While a number of
create an environment in which those with asthma QOL questionnaires are available, with some
feel free to comment about the treatment in relation intended for specific age groups, the most com-
to its effect on their lives. If the person with asthma monly used ones in practice for asthma are:
doesn’t volunteer the information, the healthcare
professional should use gentle questioning. • Asthma Control Test (ACT)
Quality-of-life (QOL) scores are an essential • Asthma Control Questionnaire (ACQ)
objective measure about how the person with • Asthma Therapy Assessment Questionnaire
asthma feels about their health and life overall. (ATAQ)
Studies have been done on the effect of asthma • Test for Respiratory and Asthma Control in
on the lives of people with asthma [110, 111]. A Kids (TRACK)
Table 6.10 Validated quality-of-life questionnaires

LEVEL OF CONTROL
Questionnaire Controlled Poor Very poor
ACT </= 20 16–19 </= 15
ACQ </= 0.75 >/= 1.5 N/A
ATAQ 0 1–2 3–4
TRACK >/= 80 70–80 <70
Asthma APGAR 0 1–2 >2
• Asthma Control and Communication nym for the healthcare provider to ask ques-
Instrument (ACCI) tions about Activities; Persistence; triGgers;
• Asthma APGAR (with PLUS) Asthma medications; and Response to
therapy.
Levels of control according to each of these After an Asthma APGAR questionnaire is
tests are shown in Table 6.10. completed, the provider follows the specified
The ACT, which is most commonly used, has procedure to get to PLUS (Plan, Lung Function,
five questions and is available in two versions— and Inhaler and Steroid Uses). It also reminds
for children aged 4 to 11 and for those aged 12 them not to substitute an exacerbation visit with a
and above. The ACQ has seven questions includ- management visit.
ing one on spirometry (a shortened version has QOL is important because it is correlated to
just five questions). The ATAQ has 20 questions the degree of control of the asthma. It allows per-
for adults, has a 7-question version for those aged sons with asthma:
5 to 17, and is often used for research. TRACK
has five questions for parents of children under • To see their progress (or the lack thereof) from
the age of 5. A TRACK score change of 10 or one visit to the next
more points (out of 100) represents a clinically • Assuming that the prescribed regimen is fol-
meaningful change in asthma control. lowed and inhaler technique is optimal, to
The ACCI, for those aged 12 and above, was assess the treatment regimen and determine if
developed for social and ethnic minorities. It uses it is successful or not
a simple scoring system with color-coded boxes. • To let their healthcare provider know how the
If all 12 green boxes are selected, asthma is con- asthma is affecting them
trolled. If any yellow boxes are selected, then the
asthma is partly controlled, and any brown/red It can help validate what they have been told
boxes indicate uncontrolled asthma. Nine ques- by the asthma educator and their healthcare pro-
tions span four domains that include three ques- vider. Above all, they soon realize that their input
tions on risk, one on “bother,” five on control, and is important and that they are a part of the asthma
one on direction of symptoms. There are also one team.
question on adherence and an open-ended ques- Thus, at every visit, individuals with asthma
tion that states “What would you like your doctor should:
to know about your asthma?”.
Some clinics use the Asthma APGAR test • Be assessed for asthma control
[118]. This was developed to improve imple- • Complete a quality-of-life questionnaire
mentation of the guidelines and provides a • Be checked for appropriate medication adher-
detailed management and care algorithm. ence and device technique
Asthma APGAR4 is a reminder and an acro- • Be asked if there are any side effects from the
medications
This must not be confused with the Apgar score used at
4 • Be questioned about any concerns
delivery to assess newborns, a test named after Virginia • Be given appropriate and timely education
Apgar, and introduced in 1952.
References 217
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Inhalation Devices Used in Asthma
7
Contents
7.1.1 Metered Dose Inhalers (MDIs) 225
7.1.1.1 Technique 226
7.1.1.2 Spiriva Respimat 227
7.1.1.3 MDI Replacement 228
7.1.1.4 Storage 228
7.1.1.5 Priming the HFA Inhaler 229
7.1.1.6 Common Errors with MDIs 229
7.1.1.7 Disadvantages of the MDI 230
7.1.2 Spacers and Valved Holding Chambers 230
7.1.2.1 Valved Holding Chambers 231
7.1.2.2 Requirements of a Chamber or Spacer 232
7.1.3 Dry Powder Inhalers (DPIs) 235
7.1.3.1 Common Errors with DPIs 236
7.1.3.2 Aerolizer 236
7.1.3.3 Diskus 237
7.1.3.4 Ellipta 238
7.1.3.5 RespiClick 239
7.1.3.6 Digihaler 240
7.1.3.7 Twisthaler 241
7.1.3.8 Turbuhaler 242
7.1.3.9 Flexhaler 243
7.1.3.10 Wixela Inhub 244
7.1.4 Nebulizers 245
7.1.4.1 Advantages and Disadvantages 246
7.1.4.2 Technique 247
7.1.4.3 Ultrasonic Nebulizers 247
7.1.4.4 Substitute Devices 247
7.1.5 Choice of Inhaler Devices 248
7.1.5.1 Considerations in Choosing a Device 248
7.1.5.2 Choosing a Device 249
7.1.6 Application 250
References 251
224 7 Inhalation Devices Used in Asthma
via an inhalation device. Numerous delivery

Key Points devices are currently in use, but they are not
• Medications and environmental control equally efficient or effective. The amount of medi-
are both important in asthma control. cation actually inhaled from a device can vary up
• Medication in any medical condition, to 400% depending on the device. In one review
including asthma, must get to the target [1], it is stated “there is however, a distinct lack of
tissue. evidence-based guidance for healthcare providers
–– Delivery of any medication may be on how to choose an appropriate inhaler.” The
topical, oral, or intravenous. rates of incorrect inhalation technique between
–– In asthma, topical delivery of medi- devices vary considerably. Devices vary in inhala-
cation is to lung tissue via inhalers. tion flow rate, inhalation volume, and particle size.
• Inhaled medication will only be able to Information on the current devices is provided to
control the asthma if the device is used help ensure the right device is used for the right
with impeccable technique. person with asthma. This is not easy for study
• Delivery methods for inhalation cur- assessment, and endpoints and patient populations
rently available are metered dose inhal- are not standardized in published studies.
ers, dry powder inhalers, and nebulizers. Nebulizers, with air or oxygen bubbling
–– Each delivery method is described through a solution of medication, were the first
together with its various devices, their inhaled delivery devices. There are now many
use, care, cleaning and replacement. other devices available. The two broad groups are
• The factors leading to device selection metered dose inhalers (MDIs) with medication in
are listed in detail. an aerosol and dry powder inhalers (DPIs) in
Specific instructions on the use of each which the person with asthma forcibly inhales
device are given. the medication.
Devices are patented, just like medications.
Typically, the manufacturer of a medication will
make it available with a specific device, and the
Chapter Objectives manufacturer will have patents on both or will
have formal licensing arrangements. Just as each
After reading this chapter, you should be medication will be governed by a patent, so will
able to: every device. The educator may want to use medi-
cation A as being most appropriate for a particular
1. Describe the different devices and
person with asthma. Following an assessment, the
explain how to use them educator may feel device B is most appropriate for
2. List the common mistakes that individu- that person. Unfortunately, specific medications
als with asthma make when using the will be packaged in one particular device only, as
different devices allowed by the patents, so the “ideal” medication/
3. List the factors that are essential in con- device combination may be unavailable.
sidering a device for an individual with Current devices are efficient; none are perfect.
asthma Each one has advantages and limitations to be
considered when helping the person with asthma
make a choice [2–4]. As noted, the possible
choices of device/medication combination are
7.1 Introduction limited, and the educator must have a full under-
standing of what is available locally.
By and large, topical delivery of any medication is “Inhaler competence” is essential. Issues can
likely to lead to benefit with a lower total dose, and be grouped as relating to the device, the person
fewer side effects, compared with systemic admin- with asthma, and the healthcare professional [5,
istration. In the case of asthma, topical delivery is 6]. A recent systematic review of the literature
noted that inhalation technique errors increase that a single Ventolin MDI emits the CO2e equiv-
with age [8]. There may occasionally be cultural alent of a car making a journey of 69 miles
barriers with a preference for oral medications, (110 km). The authors [13] recommended switch-
and some HFA inhalers may contain alcohol. The ing from MDIs to DPIs to not only reduce CO2e
devices differ one from another, each one requir- but also for the financial savings involved. It is
ing different skills and each requiring education. If not surprising then that with the increasing
the person with asthma is on more than one inhaled emphasis on climate change and efforts to reduce
medication, the educator should use the same type global warming, the pharmaceutical companies
of device for all medications. If one individual has are expected to introduce a new propellant in the
more than one type of device for different medica- near future.
tions, and this cannot be avoided, extra careful The MDI is an effective and efficient delivery
teaching of each device is imperative. system with many advantages that include being
Even for those patients who have been light, being portable, providing multiple doses,
trained, 50% will not maintain correct technique and being relatively easy to use [2]. Nowadays, it
over time [8], though frequency of review sig- is usually delivered via a “spacer” or holding
nificantly decreases the number of mistakes chamber that improves delivery but is cumber-
made [9, 10]. It has also been shown that appro- some. When the MDI is used without a spacer,
priate education of patients by trained profes- disadvantages include:
sionals in the use of their inhalers significantly
improves clinical outcomes and quality of life • High oropharyngeal deposition
for patients [11]. • A requirement for hand-breath coordination
The healthcare beliefs and device preferences • Breath hold for 10 s
in persons with asthma must be explored. The • An inability to change the dosage of medica-
health professional is really important in ensur- tion in an individual puff
ing good device choice, in offering effective edu- • A difficulty in noting the number of doses
cation and in consistent follow-up, with a focus remaining if it does not have a counter
on maintaining skills in device use and in encour-
aging adherence. These are skills exemplified by When the MDI is activated, a puff of the drug
asthma educators. is released as aerosolized particles, together with
the propellant and additives (excipients including
surfactants and lubricants or solvents). Particle
7.1.1 Metered Dose Inhalers (MDIs) size will vary depending on the formulation, type
of propellant, evaporation rate, and humidity
The metered dose inhaler was the first available [15]. The aerosol emerges at about 60 miles
portable device. Initially, the drug was combined (100 kilometers) per hour. Given that this fast-
with a propellant (generally chlorofluorocarbon moving puff needs to be carefully coordinated
or CFCs) and a surfactant. By international agree- with inspiration, the difficulties are obvious. For
ment, CFCs were phased out, and the MDIs cur- this reasons, holding chambers and spacers have
rently contain hydrofluoroalkane (HFA). Like been developed and should always be used.
CFCs, HFAs have implications for global warm- Spacers, which act as holding chambers, mini-
ing [12]. Wilkinson et al. [13] compared the car- mize the side effects of the MDI and maximize
bon footprint of MDIs, breath-activated inhalers the effectiveness of the medication. The spacers
(BAI), and DPIs used in asthma. They found that “hold” the aerosolized medication until it has
the CO2 equivalents (CO2e) in, for example, one been inspired by the individual, possibly with
Ventolin MDI inhaler produced 28 kg CO2e, two or more inhalations. When a puff of the drug
while a similar DPI produced <1 kg. In effect, the is released into the chamber, large particles tend
MDI released 28 times more CO2e, per dose, than to adhere to the sides, and smaller particles are
a DPI. Considering that a 9 mile car trip typically inhaled directly. The individual controls the rate
has a carbon footprint of 4 kg [14], this means of inspiration.
Many different designs of spacers exist, for 4. Breathe out to the side, away from the
individuals of all ages. They maximize drug mouthpiece.
delivery to lung tissue and less of the medication 5. With mouth open, begin breathing slowly,
impacts and deposits in the oropharynx. In addi- and press down on the canister while con-
tion, they decrease caregiver exposure to tinuing to breathe in deeply.
medication. 6. Close mouth and hold the breath for as long
When spacers or holding chambers are used as possible—for a minimum of 10 s.
for the delivery of inhaled corticosteroids from 7. Breathe out slowly.
an MDI, their side effects are minimized; the 8. Wait 30–60 s before repeating the process.
incidence of thrush, in particular, is reduced. 9. To take a second dose, repeat Steps 1 through
Despite the availability of spacers with their 8.
increased efficacy and lower chance of side effects, 10. Replace cap on inhaler (Fig. 7.1).
sometimes, someone with asthma may still use the
MDI directly. This may be because the spacers are Closed Mouth Technique
bulky and may not always be carried in a pocket or Again, this is not a recommended method. It is
purse. Also, the MDI’s ease of use may lead to included for those with asthma who will not use
misuse for frequent symptoms and to avoidance of a spacer.
long-term therapy. Use of an MDI by itself is not
recommended; even with good technique; only 1. Remove cap and shake inhaler.
between 10% and 25% of the drug from a metered 2. Breathe out to the side, away from the
dose inhaler will reach the lungs. For those who mouthpiece.
insist on using the MDI directly, there are two 3. Hold head so that the chin is tilted slightly
acceptable methods: the open mouth and the upward.
closed mouth method. When used to administer a 4. Place mouthpiece between the teeth, resting
bronchodilator, the degree of bronchodilation by on the tongue, with lips closed firmly
either is similar. Most individuals prefer the closed around it.
mouth technique though most of the medication
impacts on the back of the throat [16].
7.1.1.1 Technique
Every device comes with a set of usage instruc-
tions that are particular to that device. Correct
usage of an MDI ensures that the correct dosage
of medication is inhaled. Hence, technique must
be reviewed at every encounter with those who
have asthma.
Open Mouth Technique

As noted, this is not a recommended method. It is
included for those with asthma who will not use
a spacer.
1. Remove cap and shake inhaler.

2. Hold head so that chin is tilted slightly
upward.
3. Place mouthpiece of inhaler at a distance of Fig. 7.1 Metered dose inhaler with cover removed.
two fingers from the mouth. (© The Asthma Education Clinic Ltd.)
5. Start breathing in slowly, AND press down tridge into the inhaler. Place the inhaler on a firm
on the canister while continuing to breathe in surface, and push down till it clicks into place.
deeply. Replace the clear base until it too clicks.
6. Hold the breath for as long as possible, for a
minimum of 10 s. Initial Priming
7. Remove inhaler from mouth. 1. Turn the clear base in the direction of the
8. Wait 30–60 s before repeating the process. arrows on the label until it clicks.
9. To take a second dose, shake the inhaler 2. Open the cap until it snaps fully open.
again and proceed as above. 3. Point the inhaler toward the ground and press
10. Replace cap on inhaler. the dose-release button.
4. Close the cap.
The expiry date is printed on the medication 5. If a mist is not seen, repeat these steps till a
canister. mist is seen.
6. After the mist is seen, repeat Steps 1 to 4 three
Cleaning more times.
The canister should be removed from the plastic 7. The inhaler is ready for use.
holder, and the holder alone should be washed in • If it is not used for more than 3 days,
warm running water. Medication residue may release one puff toward the ground.
crystallize and affect drug delivery at the nozzle • If it is not used for more than 21 days,
or hole in the plastic mouthpiece. This should be prime the inhaler as for initial priming.
clean, clear, and unclogged. If plugged, a pin may
be used to open it. The plastic holder should be Use, Care, Cleaning, and Replacement
left to air-dry, and owners must be warned not to 1. Keep the cap closed. Turn the clear base in the
wash or puncture the medication canister. direction of the arrows on the label until it
clicks (half a turn).
7.1.1.2 Spiriva Respimat 2. Open the cap until it snaps fully open.
The Respimat is a slow-mist inhaler that comes 3. Breathe out slowly and fully.
with two components—the inhaler and a car- 4. Close your lips around the mouthpiece with-
tridge containing the medication. The cartridge out covering the air vents.
has to be inserted into the inhaler prior to use, 5. Point the inhaler to the back of your throat.
and the inhaler has to be primed. This inhaler 6. While taking a slow, deep breath through your
comes with a dose indicator that starts at green mouth, press the dose-release button, and con-
and goes toward red. When it reaches the end of tinue to breathe in.
the red scale, it is empty, and the inhaler auto- 7. Hold your breath for 10 s or for as long as
matically locks so that the clear base cannot be comfortable.
turned. 8. Close the cap.
The only medication available for this device 9. Repeat Steps 1 to 8 for a second dose.
is tiotropium, a long-acting anti-cholinergic.
Hence, users should be reminded to protect their
eyes from the aerosol for it can cause dilation of Care: Store at room temperature, away from high
the pupils and blurring of vision. They should be heat, humidity, and freezing.
cautious about driving and operating appliances Cleaning: Use a damp cloth or tissue once a week
and machinery. to clean the mouthpiece, including the metal
To insert the cartridge, keep the cap closed, part inside the mouthpiece.
press the safety catch, and pull off the clear base. Replacement: The inhaler must be discarded
Write the discard by date (3 months from open- when it is empty or 3 months from opening,
ing) on the label. Insert the narrow end of the car- whichever comes first.
7.1.1.3 MDI Replacement their doses—79% by their physician, 6% by a

Since MDIs are made by different companies, it pharmacist, and 3% by a nurse. Over 60% did not
is essential that the instruction information pro- know they were supposed to keep track of their
vided is read. Once the foil package is opened, MDI doses. Of the 36% who knew they were
the person must discard the MDI at the required required to count dosages, only 24% had actually
time (anywhere from 6 to 12 months) after open- done so. Many considered their MDI empty when
ing or when the counter reads zero, whichever nothing came out of it. One in 4 subjects found
comes first. Once the product is removed from their MDI empty when they needed them for an
the foil package, it must be used within the speci- asthma exacerbation, and 1 in 12 had had to call
fied time frame to maintain efficacy and stability 911 for help [18].
of the drug. Previously, many were told to float the inhaler
Most MDIs come with a built-in counter that canister in water as a method of estimating the
displays the number of doses left after initial amount of medication remaining. This is not only
priming and which counts down after every use unreliable and inaccurate but can interfere with
thereafter. Where the MDI does not have one, the action of the inhaler [19, 20]. “Given the
counters can also be purchased to attach to canis- necessity of a reliable dose counting method, it is
ters and to record the number of doses left with clear that manufacturers should include dose
each use. counters as a standard feature of every metered-
If the device does not have a counter and since dose inhaler” [18]. In conclusion, the best method
many individuals have a great deal of difficulty to use is the counting of the number of doses used
keeping track of their medications, it is advisable if there is no counter on the MDI.
to divide the number of doses on the canister by
the number of daily doses prescribed for the per- 7.1.1.4 Storage
son. The resulting answer (quotient), in days, The MDI reliever should be carried on the per-
indicates how many days the canister will last at son and be readily available. The MDI should be
that particular dosage. The calculation should be stored at room temperature. Canisters that have
done for a new (unused) canister, and the expected been frozen may not work properly. Ideally, the
“empty” date determined using a calendar. This canister should be kept at 37°C to ensure that a
“empty date” should be written on a label and clinically effective particle size of medication is
placed on the canister. It should also be suggested released. At lower temperatures, the particle
to them that the medication be renewed 1 week size that is released tends to increase, making
prior to the “empty date.” inhalation into the lower airways more difficult.
This calculation of the predicted “empty” date In areas where temperatures can drop close to 0,
is unsatisfactory particularly since it does not it is advisable to carry the MDI in an inside
take into consideration those days when they may jacket pocket to prevent the contents from freez-
take more than the prescribed dose. If the medi- ing. HFAs are affected by cold and provide a
cation is used only when needed, then a label can consistent dosage within the temperature range
be placed on the inhaler, and they can be advised of −4° to 68°Fahrenheit (−20 °C to 20 °C)
to use tally marks to record the number of dos- throughout the life of the canister [2, 21]. In hot
ages used. The guidelines suggest counting the climates, the MDI should not be left in a locked
doses used and subtracting from the number in car where temperatures can reach above 90°F
the device. Unfortunately, not all do this. Studies (32 °C).
have shown that many healthcare professionals Some of the HFA used for MDIs contains eth-
do not know how to use inhalers correctly and anol, which causes a temporary increase in breath
fail to inform individuals under their care of the alcohol levels (but not enough to register on a
necessity of keeping track of the doses used [4, breathalyzer). Deposition rates will vary depend-
17]. Sander and colleagues surveyed 342 adults ing on the type of holding chamber used. The
with asthma. Only 36% were told to keep track of HFAs are safe and effective [22].
All MDIs should be stored stem down or on its educator must accept responsibility for incorrect
side. device usage [23].
The most common errors are:
7.1.1.5 Priming the HFA Inhaler
The MDIs currently available require priming not • Failure to breathe out to functional residual
only prior to use but also if the inhaler has not capacity before actuating the device
been used for a period of time or if it has been • Failure to coordinate actuation with
dropped. Prior to priming the inhaler, it must be inhalation
shaken vigorously. Each device has different • Releasing the aerosolized medication into the
requirements, and these are shown in Table 7.1. mouth without inhaling
Priming is necessary to ensure that the solution is
thoroughly mixed so that a full dose of medica- Other errors [2, 6, 7, 22–26] include:
tion is made available for inhalation.
• Failure to prime before use or after a period or
7.1.1.6 Common Errors with MDIs non-use
While MDIs are convenient, efficient, portable, • Failure to shake the canister before use
and cost-effective, they also require coordination • Failure to coordinate inhalation and actuation
and slow inhalation. A major skill of the educator • Failure to hold the breath at least 6 s after
is understanding the many different ways in inhalation
which problems can manifest. As discussed sev- • Inspiration that is too rapid
eral times in Chapter 6, when there is a lack of • Repeated actuation of the device on the same
response, or a suboptimal response to prescribed inspiration
medications, several items need to be considered. • Using the inhaler when the mouthpiece is not
One major item is device use, whether related to clean
adequate skills or simply to poor adherence. Both • Repeated actuation of the device with insuffi-
of these have many subsets that need to be cient time in between actuations
explored. The word “error” is in common use as • Failing to sit up straight or stand
descriptor of things to look for. Responsibility for • Tilting the head back [27]
the error or mistake should not be assigned to any • Discontinuation of inhalation when the aero-
one party; both the person with asthma and the sol cloud strikes the back of the throat
Table 7.1 Priming the HFA MDIs

Generic name for HFA MDIs Brand Initial prime After delay
Albuterol Proventil 4 2 weeks 4
Ventolin 4 14 days or dropped 4
ProAir 2 14 days 3
Levalbuterol Xopenex 4 3 days 4
Tiotropium Spiriva 3a 3 days 1
21 days 3a
Beclomethasone dipropionate Qvar 2 10 days 2
Ciclesonide Alvesco 3 10 days 3
Fluticasone propionate Flovent 4 7 days or dropped 1
Flunisolide Aerospan 2 14 days 2
Mometasone Asmanex 4 5 days 4
Fluticasone + salmeterol Advair 4 28 days or dropped 2
Budesonide + formoterol Symbicort 2 7 days or dropped 1
Mometasone + formoterol Dulera 4 5 days 4
Note: Prime only after shaking well
a
After spray becomes visible
• Inhalation through the nose instead of the MDI is stored with its stem down. Hence, the
mouth device must be stored with the stem up [30].
• Swallowing the medication instead of One of the problems of the MDI alone is the
inhaling impact of the aerosolized particles at the back of
• Exhalation during activation of inhaler the mouth resulting in a gag reflex [31, 32]. The
• Putting the wrong end of the inhaler in the large oropharyngeal deposition of the MDI alone
mouth may lead to a reaction to the additive agents and
• Holding the inhaler in the wrong position to short-term bronchoconstriction.
• Failure to remove cap before use Where there is no counter, the lack of indica-
• Multiple actuations prior to a single tion of the number of doses remaining is another
inhalation disadvantage of the MDI that applies whether the
• Using the inhaler when it is empty MDI is used alone or with an accessory device.
• Storing the inhaler with mouth down After the number of labeled doses, the MDI will
run out of formulation, so the amount of medica-
It is important to shake the canister well before tion received will no longer be consistent and
use as the drug and solvent tend to separate in the may even be considerably reduced. This is known
canister. Activation without shaking will provide as the “tail off” [29]. Users may feel that the med-
either too much drug or too much solvent. It will ication is no longer effective.
also result in the final doses from the canister MDIs that have counters vary in how the count
being either too high or too low [28]. is displayed. In some MDIs, the counter will
Before a new canister is used for the first time, show red to indicate that there are less than 20
it should be shaken thoroughly. Then, the first doses remaining. Encourage the individuals with
few doses (2–4 depending on the medication) asthma to read the manufacturer’s guidelines to
should be “loaded” and discharged into the air, understand the counter display and to properly
i.e., they should be wasted. This is known as dispose of the device when it is empty.
priming. This will ensure the correct combination The accessory device, whether spacer or hold-
of medication and solvent is inhaled by the per- ing chamber, adds to both the bulk and the cost of
son. After a period of non-use varying from the MDI [2]. In one survey, 77% of individuals
3 days to 2 weeks, the MDI will need to be primed with asthma surveyed made at least one error
again with one to four doses expelled depending when demonstrating the use of an MDI, while the
on the medication [2]. majority had suboptimal MDI technique [33, 34].
Hence, it is essential to repeatedly review their
7.1.1.7 Disadvantages of the MDI technique [35].
If the MDI is not used for days or weeks, the Individuals with asthma often use their MDIs
propellant will evaporate or drain from the beyond the specified number of actuations due to
metering chamber resulting in a reduced dosage lack of knowledge [18, 36], failure to ascertain
or one containing no medication [29]. This is the expiry date, and not calculating the number of
known as “loss of prime” and “loss of dose,” and doses used and therefore the number of doses
it results from a brief period of non-use. When left.
the MDI is used once more, it again requires
priming.
Not shaking an MDI that hasn’t been used 7.1.2 S
pacers and Valved Holding
overnight can reduce the total and respirable dose Chambers
by 25.5% and 35.7%, respectively, because the
drugs and propellants in an MDI tend to sepa- As noted earlier, the aerosol spray is ejected at
rate—hence, shaking is essential in order to considerable speed from MDIs. Spacers and
obtain the required or prescribed dosage. Despite valved holding chambers are designed to slow
shaking, the dosage is reduced by 25% if the down the spray [37]. The spacer is placed on the
mouthpiece of an MDI and creates “space” medication toward the inside of the spacers,
between the mouth and the medication. The med- whereas low- electrostatic spacers improve
ication is broken into smaller droplets. They pro- drug delivery [46].
vide a reservoir of aerosolized medication that is Plastic spacers and holding chambers accu-
available for 3–5 s after actuation. A valved hold- mulate an electrostatic charge. This can be
ing chamber is a type of spacer with a one-way reduced by soaking them weekly in detergent and
valve. allowing them to air-dry. (Drying with a cloth
These auxiliary devices: will increase the static charge.)
Spacers come in a variety of sizes, though
• Allow propellants to evaporate none are as large as the large-volume holding
• Permit large particles to settle out of the aerochambers.
sol cloud prior to inspiration They are effective delivery devices. In one
• Reduce the amount of non-respirable study, beta-agonists in an MDI delivered via a
particles holding chamber were shown to be as effective as
• Allow large particles to be deposited in the nebulizers in the treatment of severe asthma in
spacer rather than the mouth or throat children [47]. A Cochrane review of 39 trials
• Are effective and make MDIs more efficient, (total of 1897 children and 729 adults) concluded
more cost-effective [38], and easy to use that nebulizers were not better than MDIs deliv-
• Reduce problems that result from poor MDI ered by holding chambers (spacers). They con-
technique. (Between 20 and 50% of individu- cluded “spacers may have some advantages
als are unable to use an MDI correctly because compared to nebulizers for children with acute
they inhale too fast or because of poor coordi- asthma” [48].
nation between actuation of the device and
inhalation [32], resulting in particles that 7.1.2.1 Valved Holding Chambers
impact in the mouth.) Valved holding chambers are spacers with a one-
• Reduce the amount of drug that is wasted due way valve. They provide medication only during
to poor inhaler technique [34] tidal breathing.
• Reduce both oropharyngeal deposition and Holding chambers come in two sizes, large-
the gag reflex that is caused when medication volume and small-volume. See Figs. 7.2 and 7.3.
from an MDI hits the back of the throat They include attachments such as infant or pedi-
• Largely eliminate the oral absorption of corti-
costeroids and therefore minimize the sys-
temic effects of high-dose ICS [39–41]
• Decrease caregiver exposure to medications
• Reduce the potential of tooth erosion associ-
ated with asthma medication [42–45]
• Are readily available and do not require
electricity
Spacers and valved holding chambers have

one significant disadvantage: they tend to be
bulky, are not easy to carry around, and are
easily damaged. There is also some concern
about electrostatic charges. While many of the
new plastic spacers have an electrostatic charge
that reduces the amount of respirable particles,
it should be noted that high-electrostatic Fig. 7.2 Spiriva Respimat. (© Boehringer Ingelheim
charges within the spacers will actually attract Canada)
Fig. 7.3 Large-volume holding chambers. (© The Asthma Education Clinic Ltd.)
atric face masks. When these are used, it is • Be a chamber into which medication can be
important that the masks fit properly. discharged and which permits inhalation over
Large-volume holding chambers deliver sig- several breaths
nificantly more medication than the small-volume • Provide a transparent face mask or mouth-
units [32, 49]. However, it is claimed that the piece that can be attached to the outlet
newer-design small-volume units are as effective • Have an inlet that fits all MDI inhaler devices
as the large-volume spacers (Fig. 7.4). • Be easily cleaned
Many models of small-volume spacers and • (For chambers) additionally include direc-
holding chambers are available. The usage tional valves that do not increase resistance to
instructions below may be employed with any breathing
holding chamber, large or small.
The dosage a spacer delivers is governed by
7.1.2.2 Requirements of a Chamber or several factors:
Spacer
The general requirements of a spacer or valved • Breathing pattern and age of the person
holding chamber are as follows. It must: • Static charge within the chamber
Fig. 7.4 Small-volume spacers. (© The Asthma Education Clinic Ltd.)
• Volume of chamber In evaluating a spacer or valved holding cham-

• Face mask design ber for potential use, the educator should assess
• Particular drug being used the size, presence or absence of a valve, flow rate
needed to open the valve, cost, durability, and
Spacers generally rely on the relatively large how compatible it is with a variety of MDIs.
tidal volumes of older adolescents and adults for If the device was formally assessed by a labo-
their effectiveness. Children, with their smaller tidal ratory or group, the educator should determine
volumes, will still benefit, but to a lesser degree. which agency or group performed the assess-
Specific comparisons between one or two ment and who paid for the assessment. For
spacers are available and are generally sponsored example, the comparison [50] of the
by manufacturers or distributors. For example, AeroChamber, OptiChamber, Space Chamber,
the AeroChamber and OptiChamber are said to and EZ Spacer mentioned earlier was done in a
be less dependent on breathing patterns of chil- university laboratory (the University of Alberta,
dren—in connection with the fine particles avail- Canada) and paid for by a non-profit organiza-
able for respiration—than the Space Chamber or tion (the Alberta Lung Association). Thus, it is
EZ Spacer [50]. Similarly, the OptiChamber is likely that the findings of this study are objective
said to be less sensitive to flow rates than the and impartial, since the manufacturers were not
AeroChamber [51]. involved.
The dosage of medication available is also • Inhale immediately

affected by incorrect usage. Multiple actuations • Wash the spacer according to the instructions
of the inhaler into the spacer, without waiting provided by the manufacturer
between actuations, will reduce the amount of • Replace the device every 6–12 months,
drug available for inhalation [52]. Dose reduction although with care they may last years
also occurs when there is a delay between actua-
tion and inhalation and is proportional to the The replacement time for these devices differs
delay [38]. The half-life of a drug in the spacer or between manufacturers. It is also dependent on
chamber is less than 10 s, and drug availability the care which it has been given. Inserts provided
drops by 81% in 20 s [53]. Two actuations can by the manufacturer will indicate when a device
reduce the drug available by 31% to 47% [53– should be replaced. These devices do not need to
56]. Drug availability is also reduced by static be replaced as long as they are clean and not
electricity that causes drug particles to accumu- cracked and the valves work properly.
late on many plastic and polycarbonate devices. The choice of a suitable device is therefore of
This can be prevented by regular soaking in a paramount importance. Appropriate use of aero-
mild detergent solution and air-drying [28, 57]. sol equipment could save between $120 million
Spacers and chambers should never be wiped dry. and $160 million annually, according to a report
One of the most important elements to be con- from the National Association for Medical
sidered when using a spacer or valved holding Directors of Respiratory Care [61].
chamber is the amount of medication it delivers.
Since different spacers will provide different out- Using an AeroChamber with Mask
puts with different inhalers, the substitution of a 1. Remove cap from inhaler device, and shake
device will not necessarily provide the equivalent well.
therapy [58]. There is little information obtain- 2. Insert device into the end of the AeroChamber
able about the amount of medication delivered opposite the mask.
through different spacers [52, 58–63]. 3. Place mask gently over nose and mouth.

The speed and volume of the aerosol cloud Ensure that the mask fits comfortably on the
will affect the amount of medication delivered by face without any gaps. Hold mask in place.
the chamber or spacer. For instance, the 4. Actuate inhaler device once.
AeroChamber with flunisolide MDI provides the 5. Hold mask in place maintaining a good seal
best results when compared with ACE, InspirEase, for six breaths. Do NOT actuate inhaler
and OptiHaler. The InspirEase, when used with again.
beclomethasone MDI, provides better output 6. Remove mask from face.
than the ACE, AeroChamber, or OptiHaler. 7. Wait 30 s before taking another dose.
However, all the abovementioned spacers work 8. If a second dose is required, remove inhaler,
equally well with albuterol [59]. shake well, and repeat the above procedure.
When choosing a spacer/chamber, the follow- 9. Replace cap on inhaler (Fig. 7.5).
ing points should be considered:
Using an AeroChamber with Mouthpiece
• Will it aid adherence? 1. Remove cover from AeroChamber
• Will it provide the required amount of drug? mouthpiece.
• Will it minimize side effects? 2. Remove cap from inhaler device, and shake
well.
An individual who uses a spacer or valved 3. Insert device into the end of the AeroChamber
holding chamber must be reminded to: opposite the mouthpiece.
4. Place the AeroChamber mouthpiece in the
• Avoid quick multiple actuations (made with- mouth.
out a pause after each one) 5. Actuate inhaler device once.
Fig. 7.5 AeroChambers. From left to right: with cap removed; with adult mask attached; with pediatric mask attached;
and with infant mask attached. (© The Asthma Education Clinic Ltd.)
6. Take a slow deep breath. Hold the breath for If the flap is brittle, curled, or cracked, the
as long as possible, at least 10 s. Then breathe AeroChamber must be replaced.
out through the mouthpiece.
7. Breathe in again. Do NOT press inhaler
again. 7.1.3 Dry Powder Inhalers (DPIs)
8. Hold breath for 5–10 s, and then breathe out.
If unable to take a deep breath, take three or The dry powder inhalers, of which there are a
four consecutive breaths. number, are all “breath-activated” devices—they
9. Remove AeroChamber from mouth. work only when the person inhales. There is no
10. Wait 30 s before taking another dose. need to coordinate inhalation and actuation of the
11. If a second dose is required, remove inhaler, inhaler. Their important advantage is that they
shake well, and repeat the above procedure. contain fewer ingredients. There are no propel-
12. Replace cap on inhaler. lants, co-solvents, or lubricants. The drug is usu-
13. Replace mouthpiece cover on AeroChamber. ally combined with a filler, generally lactose, to
provide the required bulk [28]. DPIs have the
When used correctly, the AeroChamber makes advantage of not requiring a spacer or holding
a soft hissing sound. If a whistling sound is heard chamber. However, they may be susceptible to
instead, this indicates a too-rapid inspiration. humidity. Tilting or even breathing into them
before inhalation may cause loss of dose. DPIs
Cleaning may irritate the airways. With some exceptions,
The AeroChamber and mouthpiece should be drug delivery to the airways is less efficient in
washed by hand weekly in warm water and left to DPIs compared with the MDI.
dry. They can also be washed by running water Deposition in the lungs varies from 10% to
through them. They should not be wiped dry or 30%. Drug delivery is dependent on the inspira-
placed in a dishwasher. If the flap valve on a tory flow rate. There are many situations where
holding chamber is accessible or can be inspected, DPIs are not appropriate, and they are not recom-
it is important to check that: mended for use with infants and small children.
Inspiratory flows vary according to the device
• The valve is flexible and closes properly (see Table 7.2), and children under the age of 6
• There is no build-up of medication inside will have difficulty achieving an inspiratory flow
• It is stored in a dust-free container >/= 50 liters/min [3].
Table 7.2 Minimum inspiratory flow rates so that particles may be inhaled. Individuals
Minimum Minimum must be careful not to place the capsule in the
inspiratory inspiratory mouthpiece or to swallow it. Further, the
flow rate in l/ flow rate in l/
Inhaler min Inhaler min
Aerolizer must be held so that the blue buttons
Aerolizer 16 Flexhaler 30 are horizontally, and not vertically, opposite
Breo 30 Turbuhaler 30 each other.
Ellipta The advantage of the Aerolizer is that it
Diskus 30 Twisthaler 30 requires a very low inspiratory flow and it pro-
Digihaler 60 RespiClick 60 vides visual, auditory, and gustatory (taste) indi-
Wixela 30
Inhub
cators that the drug has been inhaled. If the first
inspiration proves insufficient to inhale the entire
dose of drug (as can be verified by a visual
7.1.3.1 Common Errors with DPIs inspection of the capsule), then a second inspira-
Every DPI is designed differently so the instruction can be taken [64] (Fig. 7.6).
tions for each one are unique. Common errors
that the educator should watch for and ask about Using an Aerolizer
include [5]:
1. Remove the blue cover.
• Swallowing a capsule made for inhalation 2. Hold the base firmly and turn the mouthpiece
• Failing to pierce the capsule in the direction of the arrow.
• Continuing to pierce the capsule while 3. Check that the recess in the base is empty,
inhaling and then place a capsule in it.
• Storing the capsules in the inhaler 4. Return mouthpiece to the original position.
• Failing to load the device 5. Keep inhaler upright, and firmly squeeze the
• Shaking the device two blue buttons once to puncture the cap-
• Covering the air vents sule. Do not tilt or shake the inhaler while
• Inhaling too slowly pressing the buttons. Release the buttons.
• Trying to double-load a device 6. Breathe out to the side, away from the
• Washing the device inhaler.
• Exhaling into the device 7. Place the mouthpiece between the teeth and
• Not removing the inhaler from mouth while close lips firmly around it.
exhaling 8. Tilt head slightly back.
• Not breathing out slowly and gently 9. Breathe in deeply and steadily. A whirring
• Not taking a slow deep breath in through the sound is heard when done correctly.
mouth 10. Remove inhaler from mouth.
• Not closing the cover completely 11. Close mouth and hold the breath for as long
• Using the inhaler when it is empty as possible, at least 10 s.
12. Breathe out slowly.
7.1.3.2 Aerolizer 13. Open the inhaler and check that all medica-
This device is used for formoterol, a long-acting tion has been inhaled. If not, then repeat
beta-agonist. A capsule containing the medica- from Step 7. Do not attempt to puncture the
tion is placed inside the device. The capsule is capsule again.
pierced prior to inhalation by pressing the blue 14. Open the inhaler and remove the empty

buttons on the sides of the device. capsule.
The Aerolizer has some drawbacks: the hold- 15. Replace the cover.
ing chamber has to be cleaned prior to each use;
the capsules require storage in a dry place at An expiry date is printed on the capsule
room temperature; and the capsule may splinter package.
Fig. 7.6 Two Aerolizers. The device at left is closed, while the second has its cover removed and is opened to show the
cavity into which the capsule is placed. (© The Asthma Education Clinic Ltd.)
Cleaning This inhaler must be cleaned after The taste of the lactose carrier reassures them
each and every use. Empty capsule fragments that the drug has been inhaled. The Diskus con-
must be removed prior to the insertion of a new tains 60 doses and the blisters allow for consis-
capsule. Since there is only room for one capsule, tency in drug delivery.
this device cannot be double-loaded. The mouth- This device cannot be double-loaded.
piece and capsule compartment should be wiped Activation of the lever peels open one blister.
with a soft dry cloth or with the small brush that Reactivation of the lever without inhalation
is included with the medication, in order to merely clears away the first dose and opens
remove any powder residue. This device should another blister so that they cannot receive a dou-
not be washed. It must be kept dry. ble dose. This is also a minor disadvantage—they
must be warned that double activation of the lever
7.1.3.3 Diskus simply wastes the first dose.
This is a breath-activated inhaler and is available The device comes in a foil-wrapped package.
for fluticasone and salmeterol singly and in com- Once opened, the date must be written on the
bination. The drug is mixed with lactose and device (Fig. 7.7).
sealed in a blister, where each blister is automati-
cally pierced before inhalation—the blister in the Using a Diskus
Diskus has its lid sheared (cut) off by the loading
lever. 1. Holding the outer case with one hand, place
The Diskus has many advantages: the thumb of the other hand on the thumb
grip on the cover.
• The cover is an integral part of the device and 2. Open the device by pushing the cover side-
hence cannot be lost. ways as far as it will go, until a click is
• The foil blisters containing the drug are unaf- heard.
fected by temperature and humidity. 3. With the mouthpiece facing you, slide the
• The built-in counter indicates the number of loading lever as far to the side as possible
doses remaining (with the last five doses until it clicks.
marked in red). 4. Breathe out, to the side, away from the
• Cleaning is easier than for other devices. mouthpiece.
Fig. 7.7 Diskus. Closed (left) and open trainer device (right). (© The Asthma Education Clinic Ltd.)
5. Place the mouthpiece between the lips and This inhaler comes packed in a foil pouch.
make sure the teeth are apart. Users should be warned that the desiccant
6. Keeping the device horizontal, breathe in sachet for the device should not be eaten or
quickly and deeply. inhaled. The date the foil package is opened
7. Remove the Diskus from the mouth and hold should be written on the inhaler and the inhaler
the breath for as long as possible—at least discarded after 6 weeks whether it is empty or
10 s. not.
8. Breathe out slowly. When the mouthpiece is fully opened, a click
9. Close the device by sliding the thumb grip is heard, and the inhaler automatically advances
back toward you as far as it will go. one blister and aligns it with the mouthpiece and
10. To take a second dose, repeat the above
peels the foil cover to expose the contents of the
procedure. blister ready for inhalation. If the cover is closed
without inhaling, the dose is lost. The device can-
Cleaning: This inhaler requires very little clean- not be double-loaded. Closing the mouthpiece
ing. Wipe the mouthpiece with a dry tissue. cover resets the inhaler so that the next dose can
Do not wash. be actuated when needed.
Storage: Store in a cool dry place. The counter The inhaler is designed to stand upright. It has
numbers from 5 to 0 will show in red. a centrally positioned, large dose counter that
Replacement: Discard inhaler 1 month after counts down with each opening of the mouth-
removal from the foil pouch or when counter piece. When nine or fewer doses remain, a red
shows “0” whichever comes first. flag appears. When the last dose is inhaled, the
counter shows “0,” and if another attempt is
7.1.3.4 Ellipta made, a second red flag appears in the counter
This is a dry powder inhaler designed to include display (Fig. 7.8).
either one or two blister strips allowing for either
a single medication or a combination of medica- Using the Ellipta
tions with each medication stored separately until
inhalation occurs. The medications are flutica- 1. Hold the inhaler upright and slide the cover
sone furoate and vilanterol inhalation powder. sideways until a click is heard.
The cover is a distinctly different color from the 2. The dose counter will decrease by one

rest of the inhaler with the mouthpiece cover number.
color differing for each product, thus making 3. Breathe out, to the side, away from the

identification easy. mouthpiece.
7.1.3.5 RespiClick
This device has been replaced by the Digihaler,
but is still in use. It comes in a foil package and
contains fluticasone and albuterol. Once removed
from the package, the date should be written on
the inhaler. A counter at the back changes to red
when there are 20 doses left and displays the
remaining doses in units of 2. When the counter
shows “0,” it is empty.
Using the RespiClick
1. Hold it upright with the red mouthpiece at

the bottom, facing you.
2. Make sure it is closed before you begin using
it. Do not open the cap unless you are ready
Fig. 7.8 Ellipta—open, showing red flag that indicates it to take a dose.
is empty. (© The Asthma Education Clinic Ltd.)
3. Hold it upright and open the red mouthpiece
cover fully until a click is heard. (This loads
4. Do not block the air vent below the
the medication.)
mouthpiece. 4. Breathe out fully to the side, away from the
5. Place the mouthpiece between the lips and mouthpiece.
make sure the teeth are apart. 5. Place the mouthpiece between the lips, make
6. Keeping the device horizontal, breathe in
sure the teeth are apart, and close lips tightly.
quickly and deeply. 6. Breathe in quickly and deeply making sure
7. Remove the Ellipta from the mouth and hold the air vent above the mouthpiece is not
the breath for as long as possible—at least blocked.
10 s. 7. Remove the device from the mouth and hold
8.
Breathe out slowly away from the the breath for as long as possible—at least
mouthpiece. 10 s.
9. Close the inhaler by sliding the cover up and 8. Breathe out slowly away from the
over the mouthpiece as far as it will go. mouthpiece.
9. Close the red cap firmly over the mouthpiece.
Storage: Store in a cool dry place. 10. To take a second dose, wait 30 s and then
Replacement: Discard inhaler when counter repeat the above steps.
shows “0” or 6 weeks after date of opening
even if not empty, whichever comes first. Cleaning: Gently wipe the mouthpiece with a dry
tissue or cloth. Do not wash or put any part of
Note that the Trelegy Ellipta which con- the inhaler in water. If any part gets wet, get a
tains three different medications comes with a new inhaler.
printed form that indicates the number 60. Storage: Discard the ProAir after 13 months,
That number refers to the number of blisters in even if not empty. Discard the RespiClick
the device. When in use, the lids for three blis- AirDuo and ArmonAir after 30 days, even if
ters are removed for a single inhalation. Users not empty.
should watch the counter which initially shows Replacement: Discard inhaler when counter
20 doses and discard it when the counter shows “0” or 30 days after date of opening
shows “0.” even if not empty, whichever comes first.
7.1.3.6 Digihaler Similar in operation to the RespiClick, there is

The Digihaler is the digital version of the a dose counter at the back of the inhaler. When
RespiClick and is used to deliver fluticasone and the dose counter has 20 doses left, the counter
albuterol. It contains an electronic module built changes to red, and when it shows “0,” the inhaler
into the inhaler which senses, records, and stores is empty and should be discarded (Fig. 7.9).
information about inhalation. The electronic
module which sits atop the inhaler can send Using the Digihaler
information through Bluetooth wireless technol-
ogy to a mobile application whose use is optional. 1. Hold it upright with the mouthpiece at the bot-
This inhaler comes in a foil pouch. The date tom, facing you.
on which it is removed from the foil pouch should 2. Make sure it is closed before you begin using
be written on the inhaler since it should be used it. Do not open the cap unless you are ready to
within 13 months. take a dose.
Fig. 7.9 Digihaler, with wireless connection to a smartphone. (©Teva Canada Ltd.)
3. Hold it upright and open the mouthpiece cover

fully until a click is heard. (This loads the
medication.)
4. Breathe out fully to the side, away from the
mouthpiece.
5. Place the mouthpiece between the lips, make
sure the teeth are apart, and close lips tightly.
6. Breathe in quickly and deeply making sure the
air vent above the mouthpiece is not blocked.
7. Remove the device from the mouth and hold
the breath for as long as possible—at least
10 s.
8.
Breathe out slowly away from the
mouthpiece.
9. Close the cap firmly over the mouthpiece.
Cleaning: Gently wipe the mouthpiece with a dry

tissue or cloth. Do not wash or put any part of
the inhaler in water. If any part gets wet, get a
new inhaler.
Storage: The Digihaler should be stored at room
temperature between 59°F and 77°F (15 °C
and 25 °C) and kept dry and clean. Do not
expose this inhaler to extreme cold, heat, or
humidity.
Replacement: This inhaler should be discarded
whichever one of the following comes first:
• When the counter shows “0”
• 13 months after removal from the foil Fig. 7.10 Twisthaler. (© Merck Canada Inc.)
pouch in which it is packed
• After the expiration date that is written on after opening the foil pouch in which it is packaged
the package or when the counter reads 00, whichever comes
first, even if not empty. Thus, the date of opening
7.1.3.7 Twisthaler should be recorded on the label of the device.
This is a breath-activated dry powder inhaler con- Prior to using the device, check that the indented
taining the inhaled corticosteroid mometasone. arrow on the white section points to the dose coun-
This device does not require priming. ter in the pink base before inhalation (Fig. 7.10).
Removal of the cover loads the device. Hence,
the cover should not be removed until prior to Using the Twisthaler
inhalation. A click is heard when the cap is fully
closed. 1. Hold the inhaler upright with the pink base at
The digital dose counter in the base counts the bottom and note the counter reading.
down every time the cover is removed. When the 2. Remove the cover by twisting it in a counter-
counter reads 00, the device is empty, and the cap clockwise direction. The counter number
will lock. No further doses can be taken and the will reduce by one.
device has to be discarded. 3. Make sure the indented arrow on the white
This device locks when empty. The manufac- portion is in line with the dose counter
ture recommends the device be discarded 45 days window.
4. Breathe out to the side, away from the

Twisthaler.
5. Place the mouthpiece between the teeth and
close lips firmly around it, while holding the
Twisthaler horizontally.
6. Breathe in forcefully and deeply through the
mouth.
7. Remove Twisthaler from the mouth. Close
mouth and hold breath for as long as possi-
ble—for at least 10 s.
8. Then exhale slowly away from the Twisthaler.
9. Wipe the mouthpiece.
10. Replace the cap by turning in a clockwise
Fig. 7.11 Two Turbuhalers. The one on the right has an
direction while gently pressing down until a accessory device attached, to facilitate use. (© The
“click” is heard. Asthma Education Clinic Ltd.)
11. Make sure the arrow is in line with the dose
counter window.
12. To take a second dose, remove cover before When the Turbuhaler is shaken, only the des-
repeating Steps 2 to 10. iccant makes a sound. The sound hence cannot be
used as a measure of the drug remaining in the
Care: This inhaler must be stored at room tem- device.
perature in a cool, dry place. Do not allow The Turbuhaler cannot be double-loaded. It
canister to freeze or to get too hot. Keep dry has a cup-style system where the cups scrape
at all times. Avoid excess heat and across a tablet of medication when the base of the
humidity. Turbuhaler is rotated and “clicked.” Once the
Cleaning: After each inhalation, wipe the mouth- cups are filled, they cannot be filled again until
piece with a clean dry cloth or tissue. Do not they are emptied. Hence, this device cannot be
wash. double-loaded. The mechanism that keeps track
of the dosages taken will advance with each click
7.1.3.8 Turbuhaler even though the medication has not been con-
The Turbuhaler is efficient at delivering medica- sumed. Thus, anyone who thinks that double-
tion to the lung. It delivers budesonide, terbuta- loading can occur is in effect wasting the dosages
line, and both medications in combination. There available in this device.
are no additives, and so there is no detectable The base is color-coded. For the visually
taste. This lack of taste (and resulting lack of any impaired, this device also has a tactile marker on
sensation that a medication had been taken) is a its base (the flat portion of the grip). The
drawback for some users. Pulmicort (trade name for budesonide) Turbuhaler
When there are 20 doses remaining, a red has a Braille number 2 on the base (Fig. 7.11).
warning indicator appears in the window on the
side of the device. Some individuals may not Using the Turbuhaler
notice this and may continue to use an inhaler 1. Remove the white cover.
even when it is empty. The red sign first appears 2. Hold the device upright, and load it by twist-
at the top of the window when 20 doses are left. ing the colored grip to the right as far as pos-
It then moves downward. When it reaches the sible and then to the left till it clicks.
bottom of the window, the device is empty. The 3. Breathe out, to the side, away from the
meaning of this indicator must be pointed out to inhaler.
them and must be part of the teaching of the 4. Place the inhaler in the mouth between the
device. teeth and close lips around it.
5. Breathe in forcefully and deeply.

6. Remove the inhaler from mouth. Close
mouth and hold breath for as long as possible
(at least 10 s).
8. Wait 30 s before taking a second dose.
9. To take a second dose, repeat Steps 2
through 7.
10. Replace cover.
An expiry date is printed both on the

Turbuhaler and on its cover.
Cleaning: Do not wash. Remove the mouthpiece

and wipe clean with a dry cloth. Clean the
device once each week.
Storage: This device must be kept in a cool, dry
place. It should not be stored in a bathroom or
high-humidity area nor be allowed to get wet.
Accessory: This inhaler has an accessory device
to help those who have weak hands or arthritis
or who might have difficulty twisting the col-
ored grip at the base of the device. This is an
extended grip that can be attached to the base.
7.1.3.9 Flexhaler
The Flexhaler is the new improved version of the
Turbuhaler and is also used for budesonide and
terbutaline. The mouthpiece has been modified
with grooves placed about an inch from the tip of Fig. 7.12 The Flexhaler. (© Astra Zenenca Canada Inc. n.)
the mouthpiece to prevent the inhaler from being
placed too far into the mouth. The mouthpiece
cannot be removed and should not be twisted. This operation has to be done twice before the
The device cannot be used if the mouthpiece is device is ready for use.
detached or damaged. When loading this device, It requires a forceful inhalation which may be
it should not be held by the mouthpiece. difficult for some young children.
Like the Turbuhaler, it cannot be double- Unlike the Turbuhaler, the medication in this
loaded. It uses a cup-style system. Once the cups device is combined with lactose. It has a counter
are filled, they cannot be filled again until emp- that counts down by 10. When the device is
tied. The numerical counter will advance the empty, the number 0 appears on a red back-
counter with each click even if the medication is ground. When shaken, the sound heard is that of
not inhaled. Hence, users should be warned that the desiccant or dying agent.
they cannot take two doses at one inhalation
(Fig. 7.12). Using the Flexhaler
The Flexhaler needs to be primed before use.
This requires removal of the cover and twisting 1 . Unscrew and remove the white cover.
the colored grip to the right (or left) as far as pos- 2. Load the Flexhaler by holding it upright and
sible and then to the left (or right) till it clicks. twisting the color grip to the right (or left) as
far as possible and then to the opposite direc-

tion till it clicks.
3. Breathe out, to the side, away from the

mouthpiece.
4. Place the mouthpiece between the teeth and
close lips firmly around it.
5. Breathe in forcefully and deeply through the
mouth.
6. Remove the Flexhaler from the mouth and
hold the breath for at least 10 s.
8. To take a second dose, wait 30 s. Repeat Steps
2 through 7.
9. Replace cover and screw it shut.
An expiry date is printed on the white column

of the Flexhaler.
Cleaning: Wipe the outside of the Flexhaler

mouthpiece weekly with a dry tissue.
Storage: The Flexhaler should be stored in a cool,
dry place. It should not be allowed to get wet
nor should it be stored in a bathroom or area of
high humidity.
7.1.3.10 Wixela Inhub

This inhaler is available in a disposable gray-
colored plastic container that is sealed in a foil
pouch that should not be opened until ready for Fig. 7.13 Wixela Inhub, shown open. (© Mylan
use. On opening the foil package, the date should Pharmaceuticals ULC)
be written on the inhaler.
The inhaler contains two foil-sealed discs. The 3. With the device in a vertical position and
medications used are fluticasone and formoterol with the mouthpiece facing you, push the
mixed with lactose. This device should not be used yellow lever down to the end of the purple
in individuals with a severe allergy to milk pro- arrows until it clicks.
teins. It contains 60 doses. It has a built-in counter, 4. Breathe out, to the side, away from the
and with each closing of the cover, the counter mouthpiece.
reduces the number by one. A red warning indica- 5. Place the mouthpiece between the lips and
tor appears in the counter window when nine doses make sure the teeth are apart.
remain. The device locks after the final dose. 6. Keeping the device vertical, breathe in
This device cannot be double-loaded. It should quickly and deeply.
be stored in a dry place away from direct heat and 7. Remove the Wixela Inhub from the mouth
sunlight (Fig. 7.13). and hold the breath for as long as possible—
at least 10 s.
Using a Wixela Inhub 8. Breathe out slowly away from the device.
1. Holding the outer case with one hand, with 9. Close the device by pushing the mouthpiece
the other hand on the grip, lower the mouth- cover to the closed position.
piece cover. 10. Check that the dose counter has counted

2. Push down on the yellow lever. down by 1.
No expiry date is printed on the Wixela Inhub. explains why many individuals feel considerable
This device should be discarded when the coun- benefit from such a treatment. Because of the
ter reads “0” or 1 month after opening, whichever dosage, nebulizers have a great potential for
comes first. abuse, with many overusing symptomatic treat-
ment rather than taking an effective prophylactic
drug or not taking effective environmental pre-
7.1.4 Nebulizers cautions (Figs. 7.14 and 7.15).
The ideal particle size for the medication to
The nebulizer is not new, yet remains in common reach the bronchi is between 1 and 5 microns.
use. Many healthcare professionals think, This can be produced with gas flows between 6
wrongly, that the MDI cannot be used in infants and 8 liters per minute. A gas flow greater than
and default to nebulizer. It is also used in severe
acute asthma or in those who have difficulty in
coordination. It provides medications without the
need for coordination by the individual and can
deliver a high dose. However, it can almost
always be replaced by one of the other inhalation
devices, even in infancy.
In a nebulizer, a jet of gas (usually compressed
air) collides with the liquid medication in the
nebulizer to produce a mist or aerosol, consisting
of particles of varying sizes. As the aerosol rises
and comes into contact with a baffle inside the
nebulizer, larger particles drop out of the suspen-
sion. The aerosol is then inhaled through either a
mouthpiece or a mask. However, the mist deliv-
ers particles of varying sizes, some of which are
too large to be effective. While the system is
therefore inefficient, the high dose provides par- Fig. 7.14 Compressor with tubing, nebulizer, and mouth-
tial compensation for this inefficiency, and this piece attached. (© Pari Respiratory Equipment Inc.)
Fig. 7.15 Some of the many nebulizers available. (© The Asthma Education Clinic Ltd.)
10 L/m may reduce the time it takes for the treat- • Allow for adjustment of the drug dosage
ment but will also reduce the amount of medica- • Allow for normal breathing
tion that reaches the lungs. • Require minimal cooperation from the person
Nebulizers vary in the time they take to aero- • Are useful in the very young, very old, or
losize the medication, the size of droplets pro- those in distress
duced, and drug output, all of which have a • Do not require holding the breath
significant effect. For example, simply changing
from a nebulizer that provides a continuous mist Nebulizers also have a number of disadvan-
to one that delivers the medication only on inspi- tages. They [2]:
ration will double the amount inhaled. The output
from a nebulizer varies depending on the make, • Are time- and labor-intensive
design, age, wear and tear on the machine, vol- • Require a power source
ume of fill, the airflow through the machine, tem- • Are less portable than other devices
perature, and humidity. The medication itself can • May become contaminated
affect the output depending on the solution, vis- • Are inconvenient
cosity, surface tension, and density. Nonetheless, • Can result in overdosing
approximately two thirds of the aerosolized med- • Require cleaning after each use
ication is lost to the environment during continu- • Can cause eye contamination of the drug with
ous nebulization [28]. Since medication delivery the use of a mask
varies depending on the type of nebulizer used, it • Can cause drug exposure to healthcare profes-
is essential to use the nebulizer that is cited on the sionals and caregivers that may result in occu-
drug label to obtain the maximum effect of the pational asthma
drug. • Take anywhere from 5 min to 25 min for a
treatment (Fig. 7.16)
7.1.4.1 Advantages and Disadvantages
Nebulizers have a number of advantages. They The nebulizer cup and the compressor come in
[2]: many different designs. The “fit” of the nebulizer
Fig. 7.16 Pediatric and adult nebulizers, with attached mouthpieces and masks. (© The Asthma Education Clinic Ltd.)
and the compressor (how well one is matched to parts water for 10 min before washing. Masks
the other) needs to be checked carefully to make and mouthpieces should be treated in a similar
sure that the two together create an appropriate fashion with thorough rinsing in hot water fol-
particle size and that effective delivery is lowed by air-drying. They should not be wiped
occurring. dry.
Some nebulizers are breath-activated where
the aerosolized drug is delivered only during Treatment Time Treatment time depends on the
inspiration, thus reducing the loss of medication. rate of solution delivery, which is affected by the
pressure of the compressor, and the flow rate used
7.1.4.2 Technique to drive the nebulizer. A compressor that provides
Masks come in different sizes, and the correct the necessary medication in 8–10 min should be
size should be used. A mouthpiece instead of a selected. Machines that take longer will increase
mask is preferable for children over 3 years of the individual’s reluctance to use this type of
age [3]. Prior to use, ensure that the mask fits device [65].
properly.
The individual should be seated upright in a 7.1.4.3 Ultrasonic Nebulizers
comfortable position for the treatment. These devices use high-frequency electricity to
provide power to a transducer. This vibrates over
Steps in Using a Nebulizer a million times per second, causing the molecules
1. Place prescribed medication into cup/cham- of medication in the nebulizer to break up into
ber of the nebulizer. particles that vary between 0.5 and 3 microns in
2. Attach mouthpiece or mask to the upper end size. Thus, using an ultrasonic nebulizer increases
of the nebulizer. the amount of medication inhaled. There is no
3. Connect tubing from the air outlet on the loss to the environment since the aerosol is con-
compressor to the inlet on the nebulizer. tained until inhaled. It requires far less time than
4. Place mask over the face or mouthpiece in the jet nebulizer but expense is a major deterrent.
the mouth. Currently, ultrasonic nebulizers are not effective
5. Sit in an upright position. in aerosolizing drug suspensions such as
6. Connect compressor to power supply and budesonide and should be avoided for this pur-
turn it ON. pose [28]. Ultrasonic nebulizers are susceptible
7. Breathe slowly, pausing slightly after each to contamination, require a power source, and are
inspiration until all medication has been not always mechanically reliable [2]. Jet nebuli-
delivered and the nebulizer starts to sputter. zation of albuterol is as effective as ultrasonic
8. Turn compressor OFF, and disconnect from nebulization [66].
electrical supply.
9. Disconnect nebulizer from tubing. Remove 7.1.4.4 Substitute Devices
mask or mouthpiece. Most individuals with asthma, including infants,
10. Empty nebulizer of any remaining contents. the seriously ill, and those with coordination
Clean it and the mask/mouthpiece before problems, can be managed with an MDI and a
next use. spacer. This combination is more portable and
less bulky and can offer a more rapid response at
Cleaning The compressor must be maintained a lower cost. If the accessory device (holding
according to the manufacturer’s instructions. The chamber) is equipped with a snug-fitting mask
nebulizer should be disassembled, washed in and has an appropriately low-resistance valve
warm water with a detergent, and air-dried. and low dead space, then an MDI with holding
Encrustation can be removed by soaking the neb- chamber is an effective substitute for a small-
ulizer in a solution of one part vinegar to three volume nebulizer.
7.1.5 Choice of Inhaler Devices 7.1.5.1 Considerations in Choosing

a Device
This is clearly an individual issue, and the educa- There are essentially three areas to be considered
tor should be familiar with all devices and the when working with an individual to select a
medications associated with them. The choice of device: firstly, how well the device works for
devices will depend partly on their availability in them; secondly, their ability to use it; and thirdly,
a particular area, on a great extent on personal the appropriateness of the medication in the pre-
preference, but definitely by the medication/ ferred device. Depending on their age and ability,
device dyad. Once a decision is made about what a device should be selected for its:
is the most preferable type of medication, then
the appropriate device should be demonstrated. A • Reliability
joint decision should be made about which • Size and shape
device/medication dyad should be used, with a • Ease of use
strong bias toward the preference of the person • Ease of transportation
with asthma. • Ease of storage
The asthma educator must be familiar with all • Durability or robustness
of them, the essential method of using them, and • Which medicines are available in that particu-
also aware of common errors/problems. There lar device
are many websites available—the companies that • Cost, an amalgam of device and medication
make the devices have videos of how to use them,
and this can be shown to individuals with asthma It is essential to consider the device from the
(though they may not remember the name of the individual’s point of view. They want devices that
device). are reliable, are portable, have few steps in their
The healthcare provider will usually write a operation, are not expensive, and help them keep
prescription for medications and device. If the track of the number of doses remaining and also
educator and prescriber are working together, ones that provide feedback in terms of taste. The
device teaching can precede the writing of the challenge lies in matching the individual, the
prescription. If the educator sees a person who is medication, and the device so if they can partici-
having trouble using a prescribed device, then it pate in the selection of the device that is appropri-
may be necessary to talk to the prescriber about ate for them, it solves part of problem [67].
an alternate device. This should happen even if it Large, bulky devices such as the large-vol-
means a change, say, to a different inhaled ume holding chambers are less likely to be car-
corticosteroid. ried around and used than compact spacers.
The individual’s technique in the use of the Individuals with asthma tend to prefer devices
device should be checked at every visit. They that are easily carried in handbags, purses, or
tend to have a pattern of how they get into trou- waist packs. Durability, size, ease of storage,
ble, but as if that is not enough, they are often and transportability must therefore all be
innovative in finding new ways to use their considered.
inhaler ineffectively. Things to look out for with The cost of the devices will also determine
MDIs are lack of exhalation before use or too whether the inconvenience of carrying a large-
rapid and too forceful an inhalation. For DPIs, volume chamber is acceptable or not. Financial
educators should watch for no or less than 3 s considerations will also affect the choice of a
breath holding after inhalation and slow inhala- device. Although the healthcare provider may
tion [34]. Thus, a minimum of three instructional prescribe a device to provide a particular medica-
sessions are required to achieve some inhalation tion, the cost may make the purchase prohibitive
skill [35]. for the individual or their family. Hence, the
e ducator should know the approximate retail cost • Ability and dexterity
of each medication/device combination. • Manual strength
The cost of the device may be used together • Attitude to asthma
with the information in Table 7.3 to choose an • Attitude to medication
affordable device that provides the medication in • Lifestyle
the necessary dosage. • Place of usage
The choice of the inhaler device (the device in • Special needs
which the medication is supplied) will also • Financial situation
depend on:
Their lifestyle must be taken into consider-
• Range of doses ation when selecting a device. Device size and
• Availability of different therapies in the same compactness are requirements for an active life-
device style, particularly for children and physically
• Color coding active people. Some devices are affected by tem-
• Consistency in delivery of the drug perature—the MDI does not perform well if
• Tracking of doses taken allowed to cool to a temperature near freezing (if
• Ability to monitor usage kept in an outside jacket pocket, for instance).
• Confirmation of drug taken, whether by taste, Their occupation and recreational preferences
sound, or visual check must hence be known before the choice of device,
and its care and cleaning are discussed.
Above all, the individual’s sense of security Some other considerations:
can be assured by knowing how much medica-
tion has been consumed or is remaining in the • Teenagers prefer devices that are “high-tech”
device, as well as its ease of use during an exac- in appearance yet inconspicuous.
erbation [63]. • Diseases such as arthritis will prevent some
There are many factors that influence the individuals from using certain devices that
choice of devices, including the age of the per- require dexterity, as will extreme youth or old
son, the specific medication chosen, and individ- age.
ual preference. While asthma severity is a primary • Educators prefer devices that are easy to teach
consideration, each device must be viewed with and for which placebos are readily available.
respect to the individual’s characteristics of age
and ability. In choosing a device, considerations 7.1.5.2 Choosing a Device
must include their: Table 7.3 can help in the selection of the appropri-
ate device. It is a general guideline. Their special
• Age needs must have prior consideration when choos-
• Cognitive status ing a device. When selecting a device, it is impor-
• Visual acuity tant to consider not only the financial cost but also
Table 7.3 Selection of an age-appropriate device

Age (in years)
Device <2 2… 5… 8… 12 … 60 +
MDI + spacer + mask √ √
MDI + spacer + mouthpiece √ √ √ √ √
MDI no ? √ √ no
DPI no ? √ √ √
Note: The MDI by itself is not suitable for inhaled steroids unless it is used with a spacer or holding chamber
√ = suitable; ? = may not be used depending on dexterity and ability; no = not suitable
whether the person with asthma has the ability to When individuals with asthma are taught to
use it in acute situations. Some of the devices use the devices, significant improvements result,
require a certain minimum inspiratory flow rate to eliminating inherent or perceived differences
ensure adequate drug delivery. These rates were between devices [70]. It should be noted that
shown in Table 7.2. Children under 7 are unlikely once they are taught the correct technique, there
to achieve an inspiratory flow rate over 100 l/min. is no difference in the individual’s ability to use
Children who regularly use a breath-activated either an MDI or a DPI. This holds true even for
device may not be able to use it when there is older adults [71]. When clinically equivalent
deterioration or in an acute episode because of MDIs are used, they are the most cost-effective
the resulting drop in inspiratory flow. A peak devices for asthma treatment [70].
inspiratory flow meter can be used both to assess Individuals with asthma must be taught by
inspiratory ability and to demonstrate the correct someone who knows how to assemble, care for,
technique required by breath-activated inhalers. and use the devices correctly. However, studies
It is essential to remind them that an accessory clearly indicate that many healthcare profession-
device such as a spacer or holding chamber als lack even the rudimentary skills required for
should be used with an MDI, particularly if inhal- the selection, care, and use of these devices, often
ing corticosteroids. They: as a result of a lack of formal training [4, 15,
70–73].
• Increase the quantity of drug delivered to the Asthma educators need to be familiar with all
lungs the devices and how to use them before they can
• Reduce the risk of thrush teach anyone. Using an asthma device correctly
• Allow deposition of large drug particles in the is the most critical component of asthma educa-
device instead of the mouth tion and has long-range implications for asthma
control, self-management, and quality of life
Unfortunately, selection of the device is not [74].
the end, but merely the beginning. A review of
errors over 40 years found that prevalence of
effective technique remained at 31% with an 7.1.6 Application
equal gage of poor technique, indicating the
inhaler technique was frequently unacceptable 1. Select a placebo device that you will test on
and had not improved over the span of the ten people. Test each one separately (not in a
years [68]. group).
The individual with asthma then needs to be • Provide each person with a written copy of
taught how to use the device with clear indication instructions on how to use that particular
of where improvement is essential. Proper tech- device.
nique improves drug delivery, and this improves • Allow time to read and understand the
control and helps self-management. Mistakes in instructions, and do NOT offer help at this
technique and bad habits develop quickly. Their time.
technique will deteriorate and errors will develop • Hand out the placebo device for them to
over time. A minimum of three teaching sessions use and evaluate their technique as poor,
is essential for them to learn the technique for fair, or good. Note any difficulties and any
their inhalers [35]. Technique is rarely consistent errors.
particularly during an exacerbation. Hence, con- • Then demonstrate the correct use of the
tinued vigilance is required by the educator to device. After your demonstration, have the
ensure that their technique remains optimal. A other person use the device again. Again,
regular check on technique must be part of every evaluate technique as poor, fair, or good.
visit [34, 35, 69]. They must also be taught how Note any new or repeated errors.
to care for, store, and clean the device. • Record your answers.
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Special Situations in Asthma
8
Contents
8.1 Special Situations in Asthma 256
8.2 Pregnancy 256
8.3 Asthma in Older Adults 261
8.4 Diabetes 265
8.5 Surgery and Anesthesia 265
8.6 Occupational Asthma 266
8.7 Obesity 268
8.8 Immunization/Vaccination 272
8.9 Smoking 272
8.10 Competitive Athletes 276
8.11 Non-asthma Medications and Asthma 277
8.11.1 Aspirin Sensitivity 277
8.11.2 Sulfite Sensitivity 278
8.11.3 Antihistamines 279
8.11.3.1 Adverse Effects of Antihistamines 279
8.11.3.2 Excipients 280
8.11.4 Over-the-Counter Medications 281
8.12 Direct-to-Consumer Advertising (DTCA): Advantages
and Disadvantages 283
References 284
256 8 Special Situations in Asthma
Key Points • Advise persons with aspirin or sulfite

• Asthma is impacted when diabetes and sensitivity
obesity are present. • Discuss the use of antihistamines and
• Special and focused attention to the over-the-counter medications
identification and management of • Respond to attitudes about direct-to-
asthma in specific situations/life stages: consumer marketing
–– These include pregnancy, workplace-
related (occupational asthma), com-
petitive athletics, and a need for
surgery and anesthesia. 8.1 Special Situations in Asthma
–– Asthma may require a different
approach in older adults. Situations exist in which the standard approach to
• Immunization is important in avoiding dealing with the person with asthma—that of
illness in those with asthma, with a need working on the assumption that what one person
for some additional vaccines and pre- needs in the way of asthma treatment is true for
cautions with others. everyone else with asthma—either is inadequate
• Over-the-counter medications, includ- or needs to be adapted to meet unique circum-
ing antihistamines, but also others unre- stances and needs.
lated to asthma may impact asthma. In real life, standard approaches to asthma
–– Sensitivity to aspirin is a specific management do not acknowledge individual
example. needs and variations and do not always work,
• Sulfite is a common food additive that simply because those with asthma are real people
can exacerbate asthma. with real, but uniquely different, needs. For
• Direct-to-consumer marketing of pre- example, an individual with asthma may have
scription-only medications raises new other medical conditions or may be pregnant. If
communication issues for the asthma more than one healthcare provider is involved in
educator. making therapeutic decisions, under-treatment or
• Smoking is damaging to everyone; spe- non-treatment of the asthma may occur, or medi-
cial support is needed to help those with cations (for other conditions) may inadvertently
asthma quit smoking. be prescribed that make the asthma worse or that
interact adversely with the asthma medications.
The reverse is also true: the asthma medication
may react adversely with other medications being
Chapter Objectives used.
After reading this chapter, you should be Asthma guidelines are rightly based on evi-
able to: dence. However, the more unusual an individual
situation, the more difficult it will be to obtain
• Describe the concerns that individuals treatment guidelines or evidence from random-
with asthma have in special situations ized controlled trials or from standard textbooks.
such as pregnancy, old age, diabetes,
obesity, anesthesia, immunizations, or
vaccinations 8.2 Pregnancy
• Describe ways to deal with the person
who smokes or vapes Asthma does not affect fertility, and women with
• Give special consideration to the com- asthma are as likely to get pregnant as women
petitive athlete who do not have asthma. The asthma educator
should be skilled in helping pregnant women as
8.2 Pregnancy 257
the reported prevalence of asthma in pregnancy control. Taken together, the changes will affect
ranges from 4.1% to 8.7% [1]. Continued atten- pulmonary function and must be taken into
tion to asthma self-management is important in account when considering interventions for
maintaining good health during pregnancy. Data asthma. In addition, a sensation of dyspnea is
has suggested that for about 25% of women, common in pregnancy, increases as the preg-
asthma will improve during their pregnancy; for nancy progresses, and in some women is severe.
about 30%, it will remain unchanged. However, The growing uterus will eventually press on the
for the remaining 45%, the asthma will worsen for diaphragm, and there will be a drop in ERV and
most of the pregnancy [2] but will improve in the FRC. The thoracic cage widens slightly, so VC
last 4 weeks. A study of 189 pregnant women remains at normal or is slightly increased in vol-
found that 1 in 2 experienced a loss of control of ume. There is no change in FVC or FEV1. The
their asthma, while 1 in 5 had a moderate or severe hormonal changes, increases in estrogen and pro-
exacerbation during their pregnancy. The level of gesterone, have local effects on the airway
control was strongly associated with perinatal mucosa with hyperemia, edema, and increase in
outcomes [3]. However, asthma will generally secretions. These hormones also affect control of
return to pre-pregnancy levels of severity about 3 breathing. There is an increase in wakefulness
months postpartum [4]. Asthma severity also drive, and the sensitivity of the central and
tends to be consistent in successive pregnancies. peripheral chemoreceptors is increased. This
In addition to excitement and anticipation, results in the hyperventilation of pregnancy and
pregnancy also brings anxieties, based on real the sensation of dyspnea. As a consequence, min-
and imagined risks. The woman’s body under- ute volume increases as does tidal volume (TV)
goes many changes, and each stage of pregnancy and blood pH falls [8].
presents its own physical symptoms. There are Good control of asthma during pregnancy is
fears about the pregnancy, labor, delivery, and the important, as poorly controlled asthma, underes-
developing fetus. Pregnancy can be a time of timation of severity, and under-treatment of exac-
emotional lability, and women with asthma will erbations can lead to serious maternal and fetal
have many concerns, particularly about the complications [2]. Maternal complications
asthma and its effect on the fetus and the effect of include preeclampsia, gestational hypertension,
asthma medications. uterine hemorrhage, toxemia, induced and com-
Coexistent conditions such as diabetes and plicated labors, and need for cesarean delivery.
hypertension during pregnancy increase the risk of Fetal complications include neonatal hypoxia,
unfavorable outcomes. Sinusitis and rhinitis are perinatal mortality, intrauterine growth retarda-
common in those with asthma and should be treated tion, increased prematurity, preterm birth, and
in order to maintain control. Gastroesophageal low birth weight [4, 5, 9–11].
reflux disease (GERD) may be troublesome in any Given the consequences of poor control,
asthma situation, but it is a common issue in all excellent environmental control and carefully
pregnancies. The focus during pregnancy should be selected asthma medications are essential in
on maintaining control of both asthma symptoms pregnancy if good control is to be achieved and
and pulmonary function [3–7]. Underestimation of maintained. There are hints that mothers are
asthma severity together with under-treatment of more concerned about possible teratogenic
exacerbations can lead to adverse maternal and effects of medications than about the effect of
fetal outcomes [4]. Intervention at the earliest pos- poorly controlled asthma on the fetus. For exam-
sible moment in exacerbations must be the norm. ple, a study of over 1000 mothers with asthma in
Hence, the emphasis should be on improving the USA found that only 1 in 5 (23%) used
asthma control as early in pregnancy as possible inhaled corticosteroids, while over 50% used
and not reacting to loss of control. beta-agonists. Less than 40% of them with
Pregnancy also causes changes to the mechan- poorly controlled asthma symptoms used a con-
ics of the respiratory system and in respiratory troller medication [12].
Pregnant women, and their health professional extensively, and their use should be continued in
advisors, would be well served with high-quality pregnancy. Budesonide is the preferred choice.
objective evidence. However, evidence, no matter The guidelines [3] suggest that if pregnant
how powerful, is not enough. There must be a women are controlled on an inhaled corticoste-
strong relationship between the asthma educator roid other than budesonide, there is no reason to
and the pregnant woman with asthma. It is highly change the corticosteroid. Further, if control is
likely that the woman with asthma will have a maintained with a leukotriene modifier, then its
strong prejudice against the use of any medica- use should be continued during pregnancy.
tion during pregnancy. This is entirely under- However, a leukotriene modifier should not be
standable. Mutual respect is a basis for a gradual introduced to the regimen during pregnancy. If
introduction of information and focusing on dif- control deteriorates, then the dosage of inhaled
ferent aspects of asthma control at different corticosteroid can be increased or a long-acting
times. The pace at which this discussion proceeds bronchodilator added.
depends on the severity of the asthma. In mild General strategies used in the treatment of
intermittent asthma, string environmental control asthma, that is, achieving control and then reduc-
coupled with occasional beta-agonist use may be ing the dose to maintain control, are as appropri-
sufficient. When the asthma is more severe, the ate in those who are pregnant as they are in those
discussion will be more urgent, but must always who are not.
be respectful. The beta-2 agonists appear to be safe in fetuses
It is not possible to know with certainty and are used in pregnancy for both their alterna-
whether or not a particular medication is safe tive action that relaxes the uterine muscle and
during pregnancy, as formal studies of medica- thus delays premature labor and their usual action
tions are never performed at this time. However, on the lungs. Again, during pregnancy, the rules
some information is available. Asthma medica- for beta-2 agonist remain unchanged. That is,
tions are given to pregnant women either because these medications should be used when needed.
of necessity in severe asthma or by accident, Regular use is usually an indication that the
when a medication is given before pregnancy has asthma is deteriorating, and an increase in inhaled
been recognized. Some ideas about safety can be steroids should be recommended. There should
developed by following these pregnancies and then be a reduction in the use of beta-2 agonists.
taking note of the outcome of the treatment and Guidelines suggest that albuterol should be the
whether or not there is a problem with the preg- beta-agonist of choice, instead of terbutaline.
nancy or the fetus. Whang and colleagues With the good use of ICS, and appropriate use
describe the outcomes of observational studies in of beta-2 agonists, other medications may not be
Denmark (83043 primiparous women delivering needed. For example, consider the instance of
1999–2009) and found no association between systemic corticosteroids when there is a life-
the use of ICS and OCS in the risk of oral clefts threatening attack. Such attacks are more likely if
or congenital malformations overall [13]. Another ICS have been under-used. Despite concern about
review acknowledged that while studies have not the employment of this powerful medication, it
clarified if the use of ICS increases the risk of may be needed if acute asthma illness is present.
teratogenicity, studies have made it clear that In any exacerbation, both mother and fetus need
pregnant women with asthma who do not use ICS to be carefully monitored. If there is any suspi-
have a significantly increased risk of giving birth cion that the asthma is deteriorating, the mother
to low-birth-weight children [14]. In severe acute should use a peak flow meter to monitor her
asthma during pregnancy, prednisone and pred- asthma. The predicted values for women are in
nisolone are still essential, despite the small risk the range of 380 to 550 liters per minute, and
of both low birth weight and cleft palate [15]. these do not change during pregnancy [4].
Inhaled corticosteroids (ICS), which are the For those women receiving a biologic, there is
mainstay of asthma medications, have been used some information on omalizumab. The omali-
8.2 Pregnancy 259
zumab pregnancy registry had data on 169 The US Food and Drug Administration (FDA)
women who had omalizumab within 8 weeks has issued a warning that except for aspirin,
prior to conception or any time during pregnancy. NSAIDs should not be used regularly after
Remembering the need for caution as the num- around 20 weeks of pregnancy and beyond
bers are small, there was no increase in the inci- (October 15, 2020).
dence of major congenital anomalies, prematurity, Meticulous environmental control can help
or small-for-gestational-age compared with other minimize medication. Smoking must be avoided,
asthma studies [16]. Pregnant women already not only for the sake of the mother but also
receiving omalizumab should continue it during because of the many effects on the baby includ-
pregnancy, with careful attention to dosing as ing an increase in the risk of sudden unexpected
weight increases. However, it should probably death in infancy and of developing asthma in
not be initiated in pregnancy. early childhood. Respiratory illness in infancy is
The theophylline medications are probably associated more with maternal postnatal than
safe, but levels need to be monitored very closely prenatal smoking. Parental smoking is associated
with a suggested therapeutic range of 5 to 15 mg with more severe asthma in children [17].
per ml. In our view, these medications should be Women with asthma who have started immu-
replaced with safer medications that have the notherapy prior to pregnancy can safely continue
additional advantage of being more potent. with the current or reduced dose, but not with
The known risks of uncontrolled asthma are increased dosages. Women who are planning on
greater than the risks to the mother or fetus from becoming pregnant, or who are pregnant, should
asthma medications [4]. Pregnancy alters the not begin immunotherapy. Anaphylaxis during
elimination of medications from the body, with pregnancy has been associated with maternal and
the greatest changes taking place during the last fetal morbidity and mortality.
trimester. Medications that pose a risk to the fetus Women with asthma should be encouraged to
include [5, 10]: take the influenza vaccine, which is a killed-virus
vaccine [4]. The Centers for Disease Control and
• Decongestants (other than pseudoephedrine) Prevention recommends vaccination for all
• Antibiotics such as tetracycline, sulfonamides, women who are pregnant or who plan on getting
trimethoprim, rifampicin, and ciprofloxacin pregnant. The trivalent inactivated vaccine (TIV)
• Immunotherapy with increased dosages should be used, because the live attenuated virus
• Live virus vaccines (LAIV, trade name FluMist) is contraindicated
• Iodides during pregnancy.
They should be encouraged to seek medical
Pregnant women should also avoid the use of help when:
other medications such as decongestants and
mucolytics and over-the-counter (OTC) medica- • Medications do not provide rapid
tions that include phenylpropanolamine1, brom- improvement
pheniramine2, epinephrine, and alpha-adrenergic • Improvement is not sustained
compounds (other than pseudoephedrine) [5, 6]. • Symptoms increase and asthma deteriorates
The labels have to be read, especially the small • The exacerbation is severe
print, in all OTC medications. • Fetal kick count decreases
Not all antihistamines are safe during preg-
nancy. Diphenhydramine (Benadryl), loratadine Asthma educators can offer reassurance based
(Claritin), chlorpheniramine, and tripelennamine on evidence and emotional support to pregnant
may be used safely. women. While acknowledging that no medica-
tion is absolutely safe, they can reassure them
Used as a decongestant and appetite suppressant
1 that the medications used for asthma have not
An antihistamine
2
been shown to be harmful to the fetus, despite
extensive use during pregnancy. They can stand the importance of maintaining control over
describe the approach used by the FDA. They can their asthma is to remind them that they are also
discuss medication choices, as well as the dan- “breathing for two” and that a good oxygen sup-
gers of uncontrolled asthma, and they should be ply to the fetus depends on the mother’s lungs
given sufficient time to voice any fears. being in good shape.
They should be reminded not to use OTC anti- FeNO may have a specific place in monitoring
histamines, OTC asthma medications, cough syr- a pregnant woman’s asthma. Morten and col-
ups, or cold remedies. If an exacerbation occurs, leagues [19] used a FeNO-based treatment algo-
they should have an action plan. While they rithm combined with asthma symptoms to
should be encouraged to practice controlled monitor a group of pregnant women. The control
breathing, by exhaling through pursed lips [4], group was monitored using only clinical symp-
they must be reminded that this will not replace toms. All their children were assessed at 1, 4, and
medication. Sometimes they will hear unwise 6 years of age. The researchers concluded that
advice; for example, they may be advised by FeNO-guided asthma management during preg-
friends to re-breathe into a bag tightly held over nancy group had an effect on the offspring who
the nose and mouth and/or drink large volumes of showed a reduction in:
liquids [4]. In such cases, they must be told not to
follow such advice. • The rate of asthma
During pregnancy, they should make every • The use of short-acting beta-agonists to man-
effort to avoid respiratory infections by staying age symptoms
away from places where people congregate, • Visits to emergency
including daycare centers if possible, and wash-
ing their hands frequently. Adequate rest, exer- In short, FeNO-guided management of preg-
cise, and nutritious food should also be considered nant women’s asthma reduced the rate of asthma
essential components for a successful pregnancy. in their children in this study. More such studies
However, these are hollow precepts when there would be welcome, but use of FEV1 will also give
are already children in the family, and the educa- good results in most cases.
tor should encourage the pregnant woman to Once the baby is born, the mother who breast-
reach out to partners, family, and friends to help feeds can use inhaled and oral corticosteroids,
with child care, and increasingly so as the preg- beta-2 agonists, theophylline, and antihistamines.
nancy advances. The woman with asthma will have an infant with
Pregnant women with moderate to severe a genetic predisposition to asthma. Events in the
asthma will require more monitoring than those gestational period may well play a role in deter-
who have only mild asthma. The emphasis should mining whether this genetic predisposition is
be on the control and prevention of exacerba- translated into asthma or other allergic conditions
tions; in the case of an exacerbation, every effort [20]. It is tempting to consider limiting or forbid-
must be made to re-establish control over the ding specific food items during pregnancy as a
asthma through early intervention. Management way of preventing allergic diseases in the infant.
of asthma during pregnancy should be based on While many consider dietary restriction as “safe”
objective assessment, environmental control, the when compared with the use of medication, there
avoidance of triggers, education, and appropriate are problems inherent in this attitude. Dietary
therapy [18]. prevention programs are difficult, labor-intensive,
Women who want to get pregnant should and expensive to administer. Adherence is diffi-
make every effort to control their asthma both cult because it can be socially disruptive. The
prior to and during the pregnancy. The goal, after nature of dietary limitation also makes it difficult
all, is to have a healthy baby. Pregnant women to ensure that a diet remains nutritionally ade-
often joke that they are “eating for two.” One quate after common foods have been removed
approach that can be used to help them under- from it [21].
Studies of dietary manipulation are controver- a genetic predisposition to asthma. There is an

sial, difficult, and expensive to design and com- urgent need for well-designed studies of the
plete. The Cochrane Database conducts systematic effect of environmental changes, including
reviews of controversial topics and is an impor- dietary changes, in pregnancy on the incidence of
tant source of unbiased high-quality information. asthma in the child [25].
In a review of maternal antigen avoidance during
pregnancy, 3 trials involving 504 women were
identified [22]. The combined evidence did not 8.3 Asthma in Older Adults
suggest a strong protective effect of maternal anti-
gen avoidance on the incidence of atopic eczema Asthma may occur at any age. It is often thought
or asthma during the first 12 to 18 months of life. of as a condition of the child or young adult [26],
There was a suggestion that maternal and/or fetal yet it is a problem in middle-aged adults and cer-
nutrition might be compromised. Persons with tainly appears in older adults. For many older
atopic disease were more likely to have mothers adults, asthma may have gone into remission dur-
with asthma, be male, and be exposed to house- ing childhood and adolescent years, only to
hold smoking. return in their adult years. For some, the asthma
In a longer, prospective, randomized US study will commence only in adulthood, and others will
of food allergen avoidance, 165 children who were have the condition after aged 65, when they are
at high risk for allergic diseases were followed to considered “elderly.” The prevalence of asthma
age 7 years [23]. In the prophylactic-treated group, in this age group is the same as in the young and
the mothers avoided cow’s milk, egg, and peanut middle-aged groups [27–29].
during the last trimester of pregnancy and lactation. Before proceeding, a definition of the language
The infants avoided cow’s milk until age 1 year, used is needed in considering whether “elderly”
egg until 2 years, and peanut and fish until 4 years encompasses a homogeneous group and what the
of age. When the treated group and the group with- boundary between elderly and not-elderly might
out dietary restriction reached the age of 7, no dif- be. Orimo et al. [30] ascribe the choice of 65 years
ference was found between them in the incidence as the age of onset of being elderly to the nine-
of food allergy, atopic dermatitis, allergic rhinitis, teenth-century German politician, Bismarck. On
asthma, atopic disease, or lung function. achieving that age, in those days, people could
Anaphylaxis is such a dangerous condition participate in the national pension plan, and as
that most allergists believe that is prudent to few lived that long, the total cost of the plan would
advise atopic mothers to refrain from peanuts, hence be minimized. Now things are different.
tree nuts, and shellfish to protect their child. There is an expectation of survival into their late
Parents with children at high risk of allergic 70s or 80s, a healthy survival at that, so 65 now
disease, including asthma, will seek the educator’s seems an odd choice. One stratagem is to redefine
advice. A review [24] of actions that might reduce the terms 65–74 as “early elderly” and 75+ as
the risk of disease in the child concluded that: “late elderly.” An unspoken assumption is that the
elderly, however defined, are uniformly vulnera-
• Smoking should be avoided during pregnancy ble and a burden to society. We do not agree with
• Environmental tobacco exposure should be this assumption nor do we see those over 65 years
avoided after the child is born as a homogeneous group. Hence, the focus will be
• The baby should be breast-fed for at least on asthma and ensuring that the aim is for good
3 months control to give a full life.
• Dust mite control strategies must be Having noted the heterogeneity of those over
undertaken 65 years of age, there are, nevertheless, some com-
monalities. The chest wall is stiffer, respiratory
In summary, the pregnant woman with asthma muscles are less strong, and elastic recoil is
will be giving birth to a child that may well have reduced, and hence there is an increase in RV. There
is a reduced response to beta-agonists and cortico- • The effect of drug therapy for other conditions
steroids. Manual dexterity might be reduced, • Some general difficulties relating to aging
affecting device use. There is greater incidence of
coexisting chronic diseases in all body systems, but Caring for an older adult with asthma must be
especially of the lung. Treatments used for every seen in the context of the approach in general of
one of these other conditions may exacerbate healthcare professions to the issues of aging. The
asthma or interfere with the action of anti-asthma current attitudes have been described as “ageist”
medications. Some people may not show an FEV1 [37]. While the diagnosis of asthma can be diffi-
> 60% of a predicted normal value after a broncho- cult in individuals of any age, overall asthma in
dilator which may be related to severe airway older adults tends to be under-diagnosed and
remodelling, emphysema, and bronchiectasis [31]. under-treated [38]. While the symptoms of
Other physiological changes that should be taken wheeze, dyspnea, and chest pain are markers for
into consideration include [32]: asthma, they are also associated with a number of
diseases common to this particular age group,
• Increased rigidity and reduced strength in the such as [26, 28, 32, 33]:
chest and lungs
• Reduced ciliary clearance • Cardiovascular disease
• Reduced cough and deep breathing • Pulmonary embolism
• Reduced homeostatic response to acid/base • Chronic aspiration syndrome
balance • Carcinoma of the lung
• Reduced urinary clearance of medications and • Congestive heart failure
toxins • Chronic obstructive pulmonary disease
• Reduced drug absorption, transport, and (COPD)
catabolism
• Reduced sensory faculties—visual, hearing, Even when the diagnosis is straightforward, it
memory, and agility is much more likely to be combined with other
diseases than at any other age. Comorbid dis-
The asthma may be lifelong or a recurrence of eases [35, 39] also include hypertension, diabe-
a condition almost forgotten. Asthma may also tes, obesity, arthritis, hiatal hernia, depression,
have new onset after 65 years of age. This late- and prostatic problems in men. COPD in particu-
onset asthma is less likely to be IgE mediated or lar and congestive cardiac failure can occur
to have an allergic component [6, 26, 29, 32–34]. simultaneously. Often, the symptoms of asthma
Braman found that only 12% of individuals who are attributed to congestive heart failure and/or
developed asthma after the age of 60 had allergy- chronic bronchitis. Distinguishing asthma from
induced asthma and those with late-onset asthma other conditions is becoming more confusing,
had no history of eczema or seasonal allergic rhi- not less confusing, with recognition of the
nitis [29]. Atopy is age-related; after the age of “asthma-COPD overlap syndrome” [38]. In other
50, immediate skin test reactivity diminishes rap- words, asthma and COPD are not distinctly sepa-
idly [26]. Well-done epidemiological studies of rate conditions as once believed. The educator
asthma in older adults are rare, but the phenotype must collaborate closely with the healthcare pro-
is often severe and usually non-atopic, and vider on the diagnosis as, at any given time, one
responses to medications may differ from of congestive heart failure, COPD, and asthma
younger individuals with asthma [31]. may be producing more problems than the other
In summary, specific problems in older adults two. At a different moment in time, the condition
requiring special attention relate to [35, 36]: most responsible for symptoms may well change.
Cigarette smokers are more likely to report a
• Diagnosis concurrent diagnosis of congestive heart failure
• Presence of coexisting disease than smokers without asthma [28, 40, 41].
Further, COPD due to smoking may respond to performed in a healthcare professional’s office
anti-inflammatory medications so that the dis- every 3 to 6 months [32].
tinction between asthma and other forms of In a study at Tucson, Arizona, Enright mea-
obstructive lung disease is obscured [6]. Airway sured PEF lability in 4,581 individuals aged over
obstruction is frequently undiagnosed in older 65 years and found that PEF measured at home
adults [42]. was accurate when compared to spirometry in the
Dyspnea on exertion and wheezing are com- clinic [44]. He also found that PEF lability equal to
mon with aging [40]. Dyspnea is independently or greater than 30% was associated with asthma in
associated with chronic bronchitis, asthma, this population. The physiological changes noted
advanced age, obesity, a low FEV1, number of earlier result in reduced PEF readings. A dimin-
years of smoking, and lower levels of education ished or waning gag reflex and increased GERD
[42]. Long-standing asthma can also lead to cause more problems with increasing age [26].
chronic persistent airflow obstruction. This too General physical abilities become less with
can mimic COPD, since both chronic bronchitis increasing age. Individuals adapt to many
and emphysema are associated with fixed airflow changes as they occur gradually. However, the
obstruction. As noted, COPD and asthma are not addition of a chronic illness can lead to a sense of
nearly as distinct as once thought. powerlessness and inability to cope, which in
The Guidelines for the Diagnosis and turn results in depression [45]. A study of 103
Management of Asthma [5] advocate the use of adults (60 with asthma and 43 without) found
spirometry in the diagnosis of asthma. With spi- that though those with asthma had the same psy-
rometry, an FEV1 of less than 80% and a FEV1/ chological scores as those without, they rated
FVC ratio less than 70% are considered diagnos- their quality of life lower in terms of general
tic of airway obstruction in the older adult. health, physical role limitation, and physical
Reversible airflow obstruction of 12% and 200 ml function. Dyspnea and depression were the main
FEV1 either after bronchodilator, with repeated reasons for 61% of the variance [46]. Depression
measures over time, or after a course of cortico- may affect both the response to a diagnosis and
steroids confirms a diagnosis of asthma [6, 32]. If the willingness to comply with treatment.
oral corticosteroids are used, close monitoring is All of these physiological factors need to be
required, and non-systemic therapies intensified. considered, and the educator, with the agreement
Given the high risk of side effects, OCS should and help of the person with asthma, needs to
not last beyond 2 weeks. devise specific strategies to deal with these
There may be problems in performing spirom- problems.
etry [6]. PEF can be used, but age-related factors As noted, asthma triggers become less likely
will affect readings, and an inverse relationship to be allergenic in nature with aging. The most
has been observed between the duration of common triggers include [33, 47]:
asthma and PEF readings. A study of 114 non-
smokers aged over 60 years in the USA [41] • Viral respiratory infections
found that there was an inverse correlation • Irritants (aerosols, paints, smoke)
between the duration of asthma and percentage • Metabisulfites (in food, preservatives, beer,
predicted FEV1, as well as a lower baseline in the and wine)
FEV1/FVC ratio. These same individuals did not • Strong odors (perfumes, cleansers)
achieve normal airflow after administration of a • Aeroallergens
bronchodilator, and more than half continued to • Gastroesophageal reflux
display severe airflow obstruction after adminis- • Aspirin (ASA)
tration of a bronchodilator [40, 41, 43]. • Non-steroidal anti-inflammatory drugs
The National Institutes of Health Working (NSAIDs)
Group Report that deals with older adults sug- • Beta-blockers (including cardiovascular agents
gests that FEV1 or peak expiratory flow (PEF) be and ophthalmologic solutions)
There is more sensitivity to air pollution with • Theophylline, which should be avoided
increasing age. High concentrations of ozone and because it can cause cardiovascular side
airborne particles reduce pulmonary function; effects and tremors, and also interact with
increase respiratory symptoms, emergency room other medications. Metabolism of theophyl-
visits, and hospital admissions; and also cause an line is prolonged in the older adult, and it
increase in mortality from respiratory disease in should hence be prescribed with extreme
those aged over 65 years [48]. Advanced age and caution.
increased medication usage for a number of • High-dose beta-agonists, which promote
coexisting health conditions together increase the potassium loss and cause electrocardiogram
possibility of adverse effects from medications changes. Minor side effects of beta-agonists
[31, 49]. Medications commonly used for coex- such as tremor and blood pressure changes
isting conditions can precipitate asthma [32]. may be of greater significance in the older
These include: adult and lower their quality of life.
• Inhaled corticosteroids. At less than 1000
• ASA, usually prescribed for arthritis and pre- mcg, these appear to be well tolerated.
vention of cardiac problems. However, the higher the dose, the greater the
• Beta-adrenergic blocking agents, which may risk of side effects such as cataracts and glau-
trigger acute bronchospasm in the older adult. coma. Other side effects may induce cough,
Generally prescribed for hypertension, coro- dysphonia, loss of taste, oral candidiasis,
nary artery disease, cardiac arrhythmia, and laryngomalacia, and osteoporosis.
glaucoma, they are generally contraindicated • Oral corticosteroids, which should be pre-
for those with asthma. scribed for as short a time as possible. Side
• NSAIDs (ibuprofen, naproxen, indomethacin, effects include bone loss, thinning of the skin,
etc.), which are prescribed for musculoskele- suppressed adrenal function, cataract forma-
tal conditions but can trigger asthma in some tion, and an increase in the systemic effects of
individuals. Acetaminophen is the recom- beta-agonists. When systemic corticosteroids
mended alternative for NSAIDs. are used, monitoring levels of glucose, potas-
• Antihistamines (such as terfenadine and aste- sium, and bone and calcium metabolism and
mizole), which, when combined with diuret- for cataracts is essential.
ics, may provoke acute asthma. The
combination of antihistamines and beta- With age, the response to inhaled beta-agonists
agonists may also act as a trigger. declines. However, the anticholinergic drug
• Angiotensin-converting enzyme (ACE) inhib- ipratropium maximizes the bronchodilator effects
itors that are prescribed for hypertension. of low-dose inhaled beta-agonists and can be
These may trigger cough and obstruct the used to reduce the need for higher doses [26, 32].
diagnosis and treatment of asthma. The choice of a device in the treatment of asthma
must be given careful consideration, and the indi-
The educator must ask every person with vidual’s ability to manipulate it is of paramount
asthma to bring in all their medications, includ- importance. Arthritis is common in older adults
ing over-the-counter purchases, to ensure that and may interfere with the ability to use certain
they are not being adversely affected by either devices. Hand strength may be reduced so that
prescription or non-prescription medications. As accessory devices may have to be employed to
mentioned earlier, adverse reactions tend to manipulate inhalation devices.
increase with age [31, 32]. The use of medica- Vision might not be good enough to read
tions [32, 33, 49, 50] to control asthma must instructions, or there may be memory and audi-
always be carefully monitored. This requirement tory problems. The educator should review and
does not change as the person with asthma ages. practice specific strategies for dealing with these
Special care is needed with: limitations. See Chap. 15.
8.5 Surgery and Anesthesia 265
As inspiratory volumes fall with age, the use had been paid to the effect of diabetes on coexis-
of a holding chamber even for beta-agonists will tent asthma. In a recent review of the literature on
be of help [50]. Of course, reminders about rins- this topic, many studies were listed showing that
ing the mouth and discarding the rinse water after diabetes affects the severity and progression of
taking ICS—the “rinse and spit” approach— asthma, increasing bronchial hyperresponsive-
should be given. If an MDI is used, a spacer ness, the number of exacerbations, ED visits, and
should be used with it; again, as for ICS, the long-term mortality [55]. The mechanism might
mouth must be rinsed. Inhaler technique must be be airway hyperresponsiveness, chronic airway
checked at every visit. inflammation, and sputum overproduction. On
Immunizations, such as the annual flu shot, the other hand, most people with diabetes, par-
are advisable for everyone with asthma, whatever ticularly those who use insulin injections, respond
the age. Pneumococcal immunization is also rec- well to an asthma regimen. They also tend to con-
ommended by the CDD [51]. There are two sider asthma monitoring and treatment (by peak
pneumococcal vaccines, PCV13 and PPSV23. flow and with oral medication) easy when com-
The first is part of routine vaccination. PPSV23 is pared to diabetic monitoring (by blood test, with
recommended for those with chronic conditions, treatment by injection).
for those who are smokers, and for “all adults 65 Exercise is, of course, good for all of us, but is
years or older.” It should probably be repeated especially important in both diabetes and asthma.
every 5–10 years. There is no egg in PPSV23. Large swings in the amount of exercise per-
In those receiving immunotherapy for aller- formed from day to day will cause corresponding
gens, caution is needed as comorbidities may variations in daily insulin requirements; for this
increase the risk of dangerous anaphylaxis. reason, it is better if a regular regimen is main-
Coexistent cardiac disease is a case in point. tained. Exercise therapy, particularly regular aer-
The educator should question everyone with obic exercise, is part of diabetic treatment [56].
asthma about symptoms, particularly dyspnea, Asthma medications can be used to control
and guard against an individual minimizing their exercise-induced asthma.
symptoms, particularly dyspnea, as the expected Since thrush is common in those with diabe-
result of aging. Perception of symptoms may be tes, when inhaled corticosteroids are used,
reduced with aging [52, 53]. The fact remains, emphasis must be placed on oral hygiene, and the
however, that asthma impairs the quality of life, mouth should be assessed at every visit. While
whatever the age of the person affected. Mortality the routine use of a spacer has benefits for every-
remains high in older adults [54]. one with asthma, their value must be emphasized
There are a number of obstructive lung dis- when diabetes and asthma are present in one per-
eases in the older adult. Asthma, whether by itself son. Depending on the level of concern about
or part of the asthma-COPD overlap syndrome, ICS, leukotriene receptor antagonists may be
can be alleviated with attention to environmental considered if the asthma is milk.
controls, appropriate prescribed medication, and
adherence to an individualized treatment plan.
Age is not a barrier to good asthma care. 8.5 Surgery and Anesthesia
Asthma does not provide protection from other

8.4 Diabetes diseases, and individuals with asthma may
require surgery on either an emergency or a
Diabetes is usually seen as a disorder of sugar scheduled basis. While much of the presurgery
metabolism, but it is also a systemic disease with assessment will be done by the surgeon and the
an inflammatory component. The effect of diabe- surgical team, the educator should be part of the
tes on the renal system, retinae, and blood vessels team, ensuring the asthma is well controlled.
has been well studied, but much less attention Anesthesiologists in particular are well aware
that surgery in someone with asthma has a height- asthma, provided the person is in good preopera-
ened risk of morbidity and mortality. The mecha- tive condition and provided careful technique is
nism causing harm is probably bronchospasm used and they cooperate afterward. Smoking
and resultant hypoxemia, problems in secretion must (obviously) be forbidden.
clearance, and development of mucus plugs [57].
Most intra- and post-operative problems can
be avoided or at least minimized by careful plan- 8.6 Occupational Asthma
ning. All the medical personnel involved in a
potential surgical procedure must be aware that Occupational lung diseases (OLD), including
the patient has asthma. To ensure control is as occupational asthma (OA), are in many ways
good as possible, the person concerned should indistinguishable from other lung diseases. Most
ensure the surgeon passes on the existence of of us are familiar with the fact that coal miners
asthma to the anesthesiologist. There may be a have had their life shortened by the OLD pneu-
place for a meeting with the anesthesiologist to moconiosis. There is less familiarity with the fact
discuss the details of care, and there must be an that a degree of OLD exists in the military. The
assessment by the regular healthcare provider. In suffering of US military personnel in Southwest
addition to a physical assessment, a preoperative Asia and Afghanistan has been well documented.
pulmonary function test should be done to check The soldiers were exposed to a complex mixture
that the person is in optimum condition. of airborne projections. Pneumoconiosis and the
If systemic corticosteroids have been used in suffering of soldiers are but two examples of
the previous few months, or regular high-dose what is a very widespread problem.
ICS are in use, there may be a depressed response In terms of OA, its distinguishing feature is its
to stress. The anesthesiologist will assess whether origin. That is, OA is caused, activated, or exac-
to order a test of pituitary-adrenal function or erbated by some exposure in the workplace. Its
even consult an endocrinologist. The anesthesi- very existence is a reminder to all healthcare pro-
ologist may simply administer an additional dose fessionals to ask about current, and past, occupa-
of corticosteroids. This is in line with the NHLBI tions when seeing someone with asthma. Asthma
recommendation that individuals who have in the workplace may simply be an exacerbation
received systemic corticosteroids in the 6-month of pre-existing asthma, but can also be specific
period prior to surgery should receive corticoste- sensitization to something in the workplace, or an
roids during surgery [5]. Given the lifesaving irritant-induced reactivity related to something in
value of the extra dose of corticosteroid, other the workplace [58]. OA may be severe. In a study
considerations, such as possible delayed wound of the period 2006 to 2015, 997 subjects with OA
healing, take second place. were followed [59]. For the purpose of this spe-
Thus, the educator and the person with asthma cific study, severe asthma was defined as asthma
should review the environmental controls; requiring a “high level of treatment” and also
whether the asthma is under good control at the requiring daily reliever medication, and two or
moment; and, finally, how the medication is more severe exacerbations in the previous year,
taken—both technique and frequency. Careful or evidence of airflow obstruction on spirometry.
attention to detail is always important. Obviously, 16.2% had severe OA. Within this group of per-
those with asthma should take their regular sons with severe OA, there were modifiable fac-
inhaled medications on the day of the surgery. tors. The most obvious avoidable factor was
The anesthesiologist will provide specific instruc- continued exposure to a trigger in the workplace.
tions on oral medications. This makes even more obvious what the first step
If the person with asthma contacts the educa- should be in dealing with OA; the person with
tor or clinic, it may be to obtain information on asthma should no longer be in the workplace
the safety of surgery. In fact, surgery and anesthe- until a full assessment can be done. Other risk
sia should be no riskier than in someone with no factors include a longer duration of exposure, a
8.6 Occupational Asthma 267
history of childhood asthma, and sputum • Biocidal agents

production. • Oil mists (from coolants and lubricants during
OA can occur in a wide variety of situations. machining of metal and ceramic materials)
Information from an Occupational Disease • Wood dust (affecting construction workers,
Surveillance System provides more detailed loggers, carpenters, woodworkers, and joiners)
information. The report on adult asthma among • Ipecacuanha (medicinal root of the shrub)
workers from Ontario, Canada, was derived from • Platinum salts (at risk are workers in smelting
575,379 claims for workers’ compensation from plants)
2002 to 2013 [60]. OA was found in several • Hairdressing solutions
already well-established groups, such as bakers, • Perchlorethylene (used in drycleaning)
painters and decorators, concrete finishers, and • Polyvinylchloride (PVC)
shipping and receiving clerks. In terms of wood- • Classroom chalk (affecting teachers and some
working groups, results varied, and there was students)
reduced risk in nursing and farming groups. The • Latex (at risk are healthcare personnel and
study identified associations and is a good source laboratory and food workers)
of information of where OA is most likely to be • Green coffee beans
found. In some of the occupations, detailed • Tea
examination is required, as the overall results • Popcorn flavoring agent [69]
might be inconsistent. For example, in this study, • Reactive dyes
as noted, there was little incidence in nursing • Harvest molds (at risk are farmers)
groups overall. This might be related to the intro- • Western red cedar (affecting loggers)
duction of low powder and non-latex gloves in • Acid anhydrides
the 1990s. There may still be OA in some specific • Antibiotics
nursing groups, perhaps with exposure to, for
example, cleaning products. The above list of reactive agents is related to
Many substances that are recognized as causes occupations in which OA will occur. The list of
of occupational asthma are listed below, but such occupations will change as exposures change. A
lists can never be complete. These include more important strategy lies with the educator
[61–68]: always asking questions about occupation in the
routine assessment of everyone with asthma.
• Animal proteins (including excreta of mice, Diagnosis can be made when the worker has
rats, locust, and grain mites) respiratory symptoms with reversible airway
• Insect and plant proteins (grain, flours, latex, obstruction, and there is a relationship between
green coffee bean, and ispaghula) an agent in the workplace and the symptoms.
• Castor bean dust (at risk are laboratory work- Taking a history is by no means straightforward.
ers, seamen, and felt makers) There may be a period of weeks “or sometimes
• Isocyanates (used in adhesives, printing, rub- even years” between the first exposure and the
ber and foam manufacturing) first appearance of symptoms. Symptoms how-
• Flour or grain dust (affecting farmers, grain ever tend to become progressively more severe.
handlers, and bakery workers) They include the usual indicators (cough, wheeze,
• Epoxy resins (used in adhesives, plastic and tight chest, shortness of breath), but also eye or
paint manufacturing) nasal problems, with cough often being more
• Proteolytic enzymes (biological detergents) prominent than wheezing. Cough may first occur
• Colophony fumes (electronics and plumbing, in the evening after work or during the night.
soldering, welding) Symptoms may improve over the weekend or
• Nickel and chromium (at risk are automobile during absences from work. Whenever possible,
assemblers and repair workers) the advice of a qualified specialist in occupa-
• Formaldehyde tional health should be sought.
The criteria [66] for OA include a history of: 8.7 Obesity
• Exposure to a sensitizing agent Obesity is a disease of affluence and civilization.

• An initial symptom-free period of exposure The prevalence of obesity increased from 30.5%
• Improvement in severity of asthma symptoms to 42.4% between 2000 and 2018, and the preva-
when physically absent from the workplace lence of severe obesity in that same time period
increased from 4.7% to 9.2% [72–75]. This
The immediate action to be taken after a increase in obesity brings with it many medical
diagnosis of OA is made is for the individual to complications, and while asthma is not a compli-
be excluded from the workplace. This will cer- cation per se, the presence of both conditions in
tainly involve discussions with employers, and one person is more than coincidental. This sec-
human resource departments, and there may be tion will focus on the relationship between obe-
a need for short-term disability to support the sity and asthma and how each one makes standard
individual. In that immediate phase, two things treatment of the other more difficult. At the most
need to be done, firstly a standard assessment of basic, obesity is caused by an intake of calories
the asthma leading to appropriate therapy and greater than expenditure. Environmental factors
secondly an assessment of what exactly is such as socioeconomic status, urban living, and
involved in the workplace, as there may be factors of race and genetics are associated with
other individuals with less severe symptoms. obesity. While it can be associated with insulin
Removal from the workplace is such a major resistance and a few medical causes, obesity is
decision; it is important to examine the avail- most often related to over-eating and lack of
able evidence. Anees and colleagues studied 90 physical activity.
adults with OA and took FEV1 measurements Obesity is linked to asthma by mechanical
for at least 1 year prior to removal from expo- effects on the chest wall and airway, increases in
sure to the offending agents. They found that airway and systemic inflammation, and the
the average rate of decline in FEV1 was impact of obesity comorbidities. Obesity can
100.9 ml/year. This rapid decline was halted by cause respiratory symptoms even when there is
removal from exposure, and then it slowed to no obstructive disease [76]. Those with asthma
26.6 ml/year, a rate similar to healthy and obesity have a reduced response to many
non-smoking adults. Hence, early cessation of asthma therapies, including corticosteroids. The
exposure improved symptoms and avoided need for increased doses of corticosteroids in
excessive loss of lung function [68]. turn exacerbates the obesity. Hence, the asthma
In summary, OA is an important subset of and obesity must be treated simultaneously,
asthma. The diagnosis of OA begins with edu- always avoiding interventions for one that may
cators and others involved in looking after peo- worsen the other. Medication over-treatment is an
ple with asthma spending time taking a detailed ever-present danger to be guarded against. How
occupational and environmental history. best to achieve this has not been well studied, and
Confirmation of the diagnosis should prefera- guidelines, in our view, are too vague. On the
bly be made by a specialist [70]. Management positive side, weight reduction has been shown to
includes general asthma management together lead to an improvement in the asthma [77].
with avoidance of further exposure to the work- There are four major features of the obese-
place sensitizer [71]. Further information can asthma phenotype [78]:
be found at https://www.cdc.gov/asthma/
healthcare.html, and it provides checklists for • Worse asthma control
identifying occupational and environmental • Comorbidity related to obesity (e.g., gastro-
triggers. esophageal reflux, obstructive sleep apnea)
8.7 Obesity 269
• Decreased response to corticosteroid aging, increasing cognitive decline and suscepti-

• Metabolic and immune changes related to bility to disease, and reducing mobility. It also
obesity reduces life expectancy by almost 6 years for
men and 7 years for women after the age of 40
The worsening in asthma control is related to [74].
reduced beta-agonist effect, corticosteroid insen- It is important to quantify the degree of obe-
sitivity, and abnormal physiology. In terms of the sity. One important measurement is the body
latter, there is a reduction in expiratory reserve mass index (BMI), the weight in kilograms
volume, leading to airway closure in tidal breath- divided by the square of height in meters, or kg/
ing with drops in FEV1, FVC, total lung capacity, m2. A person with a BMI of 25–30 is considered
and functional residual capacity [79]. There may overweight, while a person with a BMI of 30 or
be difficulty in exercising regularly, with failure more is considered obese. When the body mass
of recruitment of lung units and some degree of index (BMI) is over 30, the mortality rate from all
microatelectasis. To continue the theme of one causes, including cardiovascular disease, is
condition affecting the other, severe asthma may increased by 50 to 100% in obese persons as
make regular exercise difficult and therefore be a compared to persons with normal weight [72].
predisposing factor for obesity. The National Institutes of Health categorizes
The comorbidities of gastroesophageal reflux BMI into six divisions. See Table 8.1.
and obstructive sleep apnea must be identified Waist measurement is positively correlated to
and treated. abdominal fat content and is an easy measure of
The decreased response to corticosteroid is obesity. This excess fat in the abdomen, out of
associated with systemic inflammation and proportion to total body fat, is an independent
reduced glucocorticoid receptor-α. There is a predictor of risk factors for obesity and morbid-
non-eosinophilic pattern of inflammation, neu- ity. Men who have a waist measurement greater
trophilic inflammation (women), and less atopy. than 102 cm (40 inches) and women who have a
Hence, some features that are relied on with most waist measurement of greater than 88 cm (35
people with asthma are absent. inches) with BMI in the 25–34.9 range are at high
The metabolic and immune changes related to risk for those conditions associated with obesity
obesity also have a role in the decreased response [72, 80, 81].
to corticosteroid. For example, the C-reactive Obese persons tend to:
protein, IL-6, is increased, related to systemic
inflammation. Adipokines, cytokines produced • Be prone to injury
by adipose tissue, are altered. Leptin, a regulator • Have less successful surgical outcomes
of fat metabolism, is increased, and adiponectin, • Have a low quality of life
a modulator of fatty acid oxidation, is decreased. • Suffer from psychological stress
Obesity, even without asthma, increases the
risk for a long list of diseases. For example, there While obesity can result in poor self-image, it
is an increase in the incidence of hypertension, can also lead to stigmatization, further eroding
type 2 diabetes, heart problems, stroke, gall blad-
der disease, osteoarthritis, sleep apnea and respi-
Table 8.1 Classification of weight and obesity by body
ratory problems, coronary artery disease, mass index (BMI)
dyslipidemia, osteoarthritis, a number of cancers Classification BMI (kg/m2)
(breast, colon, prostate, endometrial), GERD, Underweight < 18.5
and others. It is often the cause for menstrual Normal 18.5–24.9
irregularity, stress incontinence, and psychologi- Overweight 25.0–29.9
cal disorders such as depression [72]. The rate of Obesity (Class I) 30.0–34.9
mortality of obese persons is also higher [72, 73]. Obesity (Class 2) 35.0–39.9
Obesity directly accelerates the mechanisms of Extreme obesity (Class 3) ≥ 40
the quality of life [72, 75]. Obese persons are Table 8.2 Change in obesity rates in American children
often discriminated against in terms of employ- Change in obesity in American children and
ment and further educational opportunities, adolescents
scholarships and educational aid, pay scales, Status 1971–1974 2017–2018
Overweight 10% 16.1%
rental accommodations, and even opportunities
Obese 5% 19.3%
for marriage [72]. Severe obesity 1% 6.1%
As noted, obesity is increasing dramatically in
all ages, and this may be becoming much worse
during the COVID-19 pandemic. When last mea- unscheduled ED visits [85]. BMI and obesity
sured in 2017–2018, the prevalence of obesity tend to be higher in young people who have
was 42.4%. Among young adults between the asthma. This may be the result of exercise-
ages of 20 and 39 years, the prevalence of obesity induced bronchospasm leading to a reduction in
was 40%. It was 44.8% among middle-aged activity. A study of children with asthma, com-
adults between 40 and 59 years and 42.8% among paring those with normal weight to those who
individuals over the age of 60 [82]. Current fig- were obese, found that the latter required more
ures show that 39.6%of adults are overweight or medication to manage their asthma, wheezed
obese. The Third National Health and Nutrition more, and had more unscheduled emergency
Examination Survey (1988–1994) (NHANES) room visits [85]. Yet another study of children
found that 32.6% adults were considered over- between 4 and 17 years found that the prevalence
weight and 22.3 % were considered obese [72, of asthma and atopy rose significantly with
75]. increases in BMI [86]. A study in the UK of
Obesity, together with a combination of 14,908 children aged 4 to 11 years found that lev-
dietary factors and a sedentary lifestyle with little els of obesity were connected to asthma symp-
or no exercise, causes 300,000 deaths a year, with toms and that this BMI correlation was stronger
obesity being a major contributor. The costs to in girls than boys [87]. Castro-Rodriguez and
the American economy were estimated at others [88] also showed this gender correlation.
$99.2 billion in 1995, of which approximately Girls who become overweight or obese between
$51.6 billion were direct medical costs due to the ages of 6 and 11 were at risk of developing
diseases resulting from obesity. In 2008, those new asthma symptoms. They were also at
medical costs had increased to $147 billion [82]. increased risk for bronchial hyperresponsiveness
US national data showed a rising trend in obesity during early adolescence.
with rates of 15% in 1976–1980 doubling to 30.9 Children who are obese have higher asthma
% in 1999–2000. The 2017–2018 NHANES data and asthma-related symptoms than children con-
on American children and adolescents saw an sidered non-obese [89]. Obese children with
alarming increase in obesity [83] (Table 8.2). asthma, in a similar way to obese adults, face a
The prevalence of obese and overweight peo- number of real, and negative, health problems
ple is generally higher for racial and ethnic [90, 91] including:
minorities than it is for whites in the USA. The
highest rate for Mexican-American boys at 29% • Breathlessness and cough
was the same for African American girls, while • Impaired lung function
the Hispanic boys were at 28% and the Mexican- • Developing asthma in early childhood, includ-
American girls at 25%. The figures are higher for ing exercise-induced bronchoconstriction
African American women at 57% and 41% for • A reduced response to inhaled corticosteroids
non-Hispanic black men. Mexican-American • Psychosocial difficulties
adults also had high rates with 51% for men and • Hypertension, diabetes, and cardiovascular
50% of women being obese [83, 84]. disease in middle age (30s and 40s)
People with asthma who are obese use more • Gastroesophageal reflux disease
asthma medication, wheeze more, and have more • Hyperlipidemia
8.7 Obesity 271
• Fatty liver The educator should assess individuals for

• Insulin resistance obesity at every visit. This can be done by simple
• Obstructive sleep apnea inspection and need not involve specialized tech-
• Nutritional deficiencies niques such as measuring skin-fold thickness.
• Orthopedic complications Detailed examination, whether by palpation or by
imaging technology, will be more difficult in
Obesity in children is of grave concern since a obese persons. In dealing with obesity, the educa-
child who is obese will likely become an obese tor should:
adult. The risk of asthma increases 1.5 to 3.8
times in conjunction with increases in BMI, par- • Focus on prevention and encourage a healthy
ticularly after the age of 18 [92]. lifestyle
In women, BMI is strongly associated with the • Recognize the need for a supportive approach
risk of adult-onset asthma. Women who gain • Focus on the whole family, not just the
weight after the age of 18 are at risk for develop- individual
ing asthma in the following 4 years [93]. A US • Take a long-term view
study of female nurses aged 26 to 46 found BMI • Encourage healthy eating rather than crash
is a strong, independent risk factor for adult-onset diets
asthma [94]. A Canadian study also reported this • Clarify that moderate exercise such as a daily
correlation for females, but not male [3]. Obesity walk can be done by anyone
also increases complications in pregnancy. Higher • Review the asthma management and follow
weight prior to pregnancy increases the risk of basic principles
late fetal death, while obesity during pregnancy
increases morbidity for both fetus and mother. The last is particularly important as corticoste-
Obese pregnant women have a 10% incidence of roids, systemic and inhaled, tend to have a reduced
gestational diabetes, a tenfold risk for hyperten- effectiveness in obese asthma [97]. When the
sion, and an increased risk of congenital malfor- response to corticosteroids is below optimal, there
mation especially of neural tube defects [72]. will be a natural tendency to increase the dose. In
Women of lower socioeconomic status or low an acute situation, this may be essential and life-
education are more likely to be obese. This eco- saving, but in all other situations, alternatives to
nomic association is less consistent for men [72]. systemic corticosteroids should be explored.
Obesity-induced asthma is characterized by These include a detailed environmental assess-
being late onset, female, more severe, requiring ment and advising a rigorous plan of avoidance.
greater use of medications, low IgE levels, less In terms of medication, long-acting inhaled corti-
evidence of atopy, and being more refractory to costeroids and muscarinic agents and use of leu-
corticosteroids. The biologic immunomodulators kotriene antagonists have an important role.
likely do not have any clinical benefit since dos- In summary, obesity is a worrying and increas-
age is adjusted for weight [92]. ingly common accompaniment of asthma. Both
When present with asthma, obesity not only conditions must be addressed simultaneously. In
increases morbidity but also complicates the treat- terms of the obesity, weight reduction through
ment of both conditions. Obesity also affects the diet and exercise will help both conditions. A
severity and control of asthma [6, 94–96]. study of 14 obese asthma adults who had been
However, there is hope. Studies by Hakala and put on a low-calorie diet for 8 weeks found the
others [77] found that when obese persons reduced following results:
their weight, significant improvements in lung
function (FEV1 and FVC), symptoms, morbidity, • Decreased BMI
quality of life, and health status were obtained as • Decreased peak flow diurnal variation
well as a reduction in exacerbation and the number • Increased PEF, FEV1, and FVC
of courses of oral corticosteroids. • Increased FRC and ERV
Weight loss improved pulmonary function and may be a concern for those on ICS. If such chil-
mechanics in obese individuals and provided an dren are exposed to this very infectious disease,
increased level of control of airway obstruction medical help should be sought urgently. Annual
[77]. In terms of the asthma, general guidelines influenza immunization should be encouraged.
should be followed, with caution. Routine escala- Those with asthma should ask whoever gives
tion of doses of inhaled corticosteroids, or any them immunization about the extended pneumo-
use of systemic corticosteroids, should be coccal vaccine that covers more strains than the
avoided, unless in a crisis. As noted above, use of standard vaccine.
adjunctive medications is particularly relevant in
obesity-asthma.
8.9 Smoking
8.8 Immunization/Vaccination This is one of the most difficult—and perhaps

one of the most common—matters faced by edu-
“Vaccines are one of the most successful public cators. It is also one of the most important.
health interventions of all time” [98]. While this Educators must understand the issues and be pre-
is true, the existence of a safe, effective vaccine is pared to deal with them. Tobacco use is an addic-
insufficient: it needs to be administered before tion, and it is inappropriate to use the language of
someone is immunized and disease prevented. In blame, even though this is about people who
the COVID-19 pandemic, as vaccines are being engage in an activity that is both self-destructive
rolled out, polls show varying degrees of accep- and harmful to others. Yet the smoker needs help
tance in the population. In this section, “vaccina- and support, the goal being to help the person to
tion” and “immunization” will be used stop smoking, although the intermediate goal of
interchangeably, as seems to be the current prac- reduction may need to be accepted. Great tact is
tice. Strictly speaking, immunization is the needed when the person does not smoke but lives
protection given by vaccination. “Vaccine hesi- with someone who does.
tancy” is a real entity, even with clear evidence of
safety. The asthma educator may not be the right
person to deal with this, but the educator can Points to Ponder
direct the person with asthma, or their decision- Stages in behavior change
maker, to the website of local healthcare organi-
zations that will have on-line materials. There are 1. Pre-contemplation
contraindications involving specific immunodefi- 2. Contemplation
ciencies; again, asthma educators should refer 3. Action
questions to a qualified vaccine administrator. 4. Maintenance
High-dose systemic corticosteroids will induce a
temporary reduction in immunity. Hence, vac-
cines containing live viruses should not be
administered at this time. Given the general Most smokers know the dangers and want to
reluctance to give vaccines during acute illness, stop. Indeed, many of them make several attempts
this situation will be uncommon. before they finally succeed. It should be noted
The educator should encourage vaccination; that stopping may have become more difficult in
those with asthma do not need another illness to smokers affected by the COVID-19 lockdown.
cope with! There are few specific disease con- Stopping smoking is just one more stressor. In a
cerns that arise when someone with asthma is not report from New Zealand, “Nearly half of daily
immunized. One example is natural chicken pox smokers reported smoking more during than
infection. Life-threatening disease may arise in before the lockdown, on average, an increase of
those receiving systemic corticosteroids, and this six cigarettes a day” [99]. This was related,
8.9 Smoking 273
according to the smokers, to loneliness and isola- as ways to quit smoking. Educators will find
tion. Whatever the circumstances, the asthma these suggestions useful. For example, the web-
educator must provide support even if the smoker site advises persons wanting to quit to:
stops and restarts.
These many attempts, and the ingredients to Get ready
final success at quitting, can be understood using Get support
change theory. An overview follows (for details, Learn new skills and behaviors
please see the references for J.O. Prochaska [100, Get medication and use it correctly
101]). The idea behind change theory is that each Be prepared for relapse or difficult situations
individual is at a different stage in his or her
desire or ability to change behavior. The stages This brief list indicates that while stopping
are described as pre-contemplation, contempla- ‘cold turkey’ by oneself can be done, it is not
tion, action, and maintenance. By understanding likely to lead to a long-lasting cessation of smok-
the which stage a person is at, the educator can ing. The US Preventive Services Task Force has
offer appropriate help. reviewed the evidence for various methods of
Those at the first level may not be receptive to smoking cessation [102]. This review was very
detailed advice. The educator can give them broadly based, looking at both behavioral inter-
information. If controversy is avoided, the person ventions alone and the combined pharmacother-
can be helped to progress. Once the stage of con- apy and behavioral intervention. In essence, good
templation is reached, the educator should offer results were obtained when behavioral interven-
constructive help—for example, by providing tions were combined with pharmacotherapy. A
more information on the effects of smoking. number of behavioral interventions showed mod-
Possibly more beneficial is emphasis on the ben- est, but statistically significant, outcomes at 6
efits of stopping. The smoker will need help in months. These included “in-person advice and
imagining life without tobacco, not only in terms support from clinicians including physician
of the addiction but also in terms of relationships advice, nurse advice, individual counseling with
and relaxation. Do close friends smoke? Are a cessation specialist, group behavioral interven-
some activities associated with smoking? tions, telephone counseling, mobile phone-based
Once the individual has reached the third interventions, interactive and tailored internet-
stage—that of action or, in this case, of stop- based interventions, and the use of incentives.”
ping—strong support is needed and will continue Clear benefit was not shown for some other
to be needed for weeks. Relapse is common. The behavioral interventions. These included “moti-
final stage, maintenance, requires the greatest vational interviewing, decision aids, print-based,
vigilance, and they need to have worked out (and non-tailored self-help materials, real-time video
thought through) a plan to deal with stress. They counseling, biofeedback (feedback on smoking
also need to have a strategy to cope with situa- exposure, smoking-related disease, or smoking-
tions that, in the past, were associated with plea- related harms), exercise, acupuncture, and hyp-
sure and smoking. Even if they start smoking notherapy.” The lack of benefit may have been
again, the educator must still be supportive. Most related to the fact that evidence on each of these
smokers go through the stop/re-start cycle many was hard to find.
times before managing to stop smoking The Task Force reviewed medications used in
permanently. smoking cessations, usually combined with a
There are many excellent sources of informa- behavioral approach. One common group of
tion on smoking cessation. The CDC (Centers for medications in use are nicotine replacement ther-
Disease Control and Prevention) website, www. apy (NRT) products. The FDA has approved
cdc.gov/tobacco/how2quit.htm, is one of the best three NRT products for over-the-counter (OTC)
and gives useful advice for persons wanting to sales: transdermal nicotine patches, nicotine loz-
quit. It lists positive benefits for quitting as well enges, and nicotine gum. Two NRT approved as
prescription only are the nicotine inhaler and the healthcare provider may increase this up to
nasal spray (Nicotrol®). All showed benefit in 150 mg twice daily. It should be started 1 week
clinical trials. before they want to quit, and they should be in a
There are two non-nicotine prescription-only support program. The physician or healthcare
medications available for smoking cessation, bupro- provider and the individual will decide when to
pion hydrochloride-sustained release (Zyban®) stop taking bupropion.
and varenicline tartrate (Chantix®). There are many potential side effects, and
Bupropion is an antidepressant and is mar- anyone prescribed bupropion should read the
keted for this purpose as Wellbutrin SR®. package insert carefully. It should probably be
Bupropion’s use in smoking cessation is based on avoided in those with a history of seizures.
its nicotine receptor blocking action. There is an As far as varenicline is concerned, before
obvious risk of overdose when the same medica- starting, a quit date should be set. The tablets
tion has two different names, and both may be should be started 1 week before the quit date. The
prescribed in the same individual: Zyban as a starting dose is 0.5 mg daily for the first 3 days,
smoking cessation aid and Zyban as an then 0.5 mg twice daily on days 4 to 7, and then
antidepressant. 1 mg twice daily for 11 weeks. It is better to take
Varenicline has mixed agonist-antagonist each dose with a full glass of water, preferably
properties and has two complementary benefits. after eating. So, ideally, it should be taken after
It relieves the symptoms of nicotine withdrawal breakfast and after the evening meal.
and cigarette craving during abstinence but also The usual course of treatment is for 12 weeks.
blocks the reinforcing effects of nicotine in those When the medication is stopped, instead of a
who lapse. Varenicline may be useful in the dif- gradual reduction before stopping, a small num-
ficult situation of teenage nicotine addiction ber of people will have an increase in irritability,
[103]. an urge to smoke, depression, and/or sleeping
Some other medications are used in smoking difficulty for a short time. Varenicline is usually
cessation, although not approved specifically for well tolerated with mild nausea being the most
this purpose. These include clonidine (approved common side effect. It may also affect the ability
as an antihypertensive) and nortriptyline, to drive and use machines, so these should be
approved as an antidepressant. Cytisine is a par- avoided until the person taking it is sure they are
tial agonist of nicotine acetylcholine receptor that OK. There is a reported increase in heart prob-
is in use in smoking cessation programs and, lems and in mood and behavioral changes. If
although not FDA approved, is widely available. there is concern about potential side effects, they
Bupropion as noted above is available as should be discussed urgently with the prescriber.
Wellbutrin for depression and Zyban for smoking Nicotine replacement is available as a nasal
cessation. It is available as extended-release tab- spray, inhaler, and patch. With the inhaler, the
lets (taken at least 8 hours apart) or regular tablets nicotine is absorbed through the mouth and
(taken at least 4 hours apart). Since there are a throat, not the lungs, and takes the place of the
number of potential interactions with other medi- nicotine the smoker would get from smoking.
cations, appropriate precautions need to be taken Withdrawal effects are therefore lessened. As the
with some diseases. The usual precautions before body adjusts to not smoking, the use of the nico-
prescribing are even more important in a medica- tine replacement is decreased gradually over sev-
tion advertised under two names for different eral weeks and then stopped. As with bupropion,
indications and with potential interactions. Thus, a support program is an essential accompaniment
the full medical history must be known, along to nicotine replacement.
with any other medications, whether prescribed Individuals who obtain over-the-counter nico-
or OTC, including herbal preparations. tine replacements should be advised to check
The usual starting dose for smoking cessation with the pharmacist about contraindications
is 150 milligrams daily, taken in the morning, and related to other health problems they may have.
8.9 Smoking 275
The pharmacist should also be made aware of caution with any medication at this time. Yet the
other medications in current use. It is potentially benefits to the mother and baby of avoiding
dangerous for those who simultaneously use both tobacco during pregnancy are so great that every
over-the-counter and prescribed nicotine replace- effort must be made to help such women. If
ment therapies. women do stop smoking during pregnancy, they
It is clear that successful smoking cessation is may need help to stay off tobacco after delivery.
more likely with a combination of medication Teenagers who smoke, whether conventional
and support than with support alone. However, cigarettes or e-cigarettes (EC), are also difficult
there is no hard and fast method to determine to help. Between 2017 and 2018, EC use
which medication is most likely to be acceptable increased by 78% among high school students
and successful in an individual case. Individual and 48% among middle school students [109],
preference seems to be important [104, 105]. and the stated primary reason for using EC was
Individual, group, or telephone counseling is the appealing flavors. There is concern that EC
effective, and programs to deliver treatments are use could be the gateway to conventional tobacco
available for mobile phones in a variety of lan- use. Hammond et al. [110] studied over 44,000
guages including Cantonese, Korean, Mandarin, students in Canada and found that youth who
Spanish, and Vietnamese [106]. used EC in the month prior to the start of the
In a study of 3,575 smokers who were enrolled study were likely to start smoking conventional
in a smoking cessation program, factors related cigarettes (CC) and to continue smoking after 1
to success were noted. Women were less likely to year.
stop smoking [107]. In a study of the reasons why Second-hand smoke inhalation of EC results
it is harder for women to break free of nicotine in the same blood levels of nicotine as second-
addiction, some of the findings will be helpful to hand tobacco. EC can no longer be seen as a CC
educators as they work with women [108]. The reduction method. The implications of EC use
problems identified included the following: are far-reaching. It is, in fact, breeding a new gen-
eration of addicts hooked on nicotine [111, 112].
Women smokers are a lot more fearful, than men, Parents and healthcare providers have a major
of gaining a lot of weight if they quit. role to play in counseling youth. Educators
Women may be more susceptible than men to should inform youth, parents, and adults that
environmental cues to smoking, such as smok- [112–114]:
ing with friends or smoking associated with
specific moods. • Vaping devices contain nicotine
Many women enjoy the feeling of control associ- • Nicotine is addictive
ated with smoking a cigarette. • Inhalation of vapor will result in irritation,
inflammation, and respiratory disease
These problems are easily understood; once • Nicotine from vaping may be similar to levels
recognized, they can be dealt with by anticipa- from CC
tory guidance. • Exhaled EC vapors contain nicotine that is
Educators need to be aware that husbands may deposited on indoor surfaces
provide less effective support to wives than wives • EC vapor is toxic
to husbands. Relevant biological issues are that • EC is not harm less
nicotine replacement therapy may not be as effec- • EC is associated with progression to more
tive for women and that responses to anti- dangerous forms of smoking
smoking medications may vary with menstrual • There exists a possible risk of seizures in
cycle phase. Tobacco withdrawal symptoms also youth and young adults
tend to vary by cycle phase.
Women who are pregnant pose difficult prob- Smoking in teenagers is a major personal and
lems, as there are obvious reasons for extreme public health problem. Appropriate peer group
support may be difficult to find. The asthma edu- In exercise-induced bronchoconstriction

cator should enlist the local lung association or (EIB), there is transient narrowing of the airways.
ASH (Action for Smoking and Health) for these EIB is preferred to the term exercise-induced
special groups. In terms of medications, neither asthma (EIA), as the latter might be taken to
bupropion nor varenicline are approved in indi- mean exercise causes the asthma. It is, in reality,
viduals under 18 years of age. Prescribers may a trigger. In Chap. 3, we mentioned that reactivity
still use these medications for teenagers, but was an important way to confirm a diagnosis of
extreme care is needed [103]. Some NRT prod- asthma. Chap. 4 mentioned that it can’t be
ucts may be approved for those aged 12–18 years; assumed that airway reactivity automatically
if there is concern, the package insert should be indicated asthma. These concepts are extended
checked. Some of the issues are discussed by by quoting Couto and colleagues “designating
Karpinski et al. [115]. EIB with asthma (EIBA) the occurrence of bron-
Finally asthma educators should join with chial obstruction after exercise in asthmatic ath-
community action groups to spearhead changes letes, and EIB without asthma (EIBwA), the
to local laws about smoking and vaping. It is also occurrence of bronchial obstruction induced by
helpful to keep a list of pharmacies that do not exercise in athletes without other symptoms and
sell tobacco. signs of clinical asthma” [116].
Hence, in athletes with asthma, the educator
can expect to find a number who have what might
8.10 Competitive Athletes be called “classical asthma,” with an atopic back-
ground, a fairly long history, and a number of
Asthma may limit the ability of individuals to triggers. Other athletes will have exercise-
exercise. This is addressed at many points in this induced bronchospasm only related to their high-
book, but this section deals specifically with the level sporting activities and will not be allergic.
effect of exercise-induced bronchospasm in Athletes in both water and winter sports have a
elite athletes. As already pointed out, many high incidence of EIBwA. These reflections on
Olympic athletes have asthma, or physiological the background to the bronchospasm interfering
changes similar to asthma, and still have great with exercise are relevant to how the educator
success in competition. Exercise in this popula- may work with the athlete. While this is an area
tion is not something merely to be encouraged; of active research, the educator can contribute to
it is their central activity, their raison d’etre. the body of knowledge by taking a detailed his-
Anything short of achieving maximum exercise tory of the very specific features of training that
performance, no matter how little, will greatly lead to exercise bronchospasm and can develop
affect competitive success. Asthma educators strategies with the athlete and the sports trainer
who work with athletes get great satisfaction on optimizing training and reducing symptoms.
from helping individuals with high motivation The World Anti-Doping Code lists substances
to exercise as hard as possible without symp- that are not permitted [117]. In this book, medi-
toms. The asthma educator will also need to cations used for asthma or related conditions will
know the basics of the sport concerned. Is it be dealt with specifically, as many of the banned
short duration? Endurance? High altitude? High substances related to performance enhancement
altitude and low temperatures? The asthma edu- are not relevant to asthma. However, if athletes
cator will also need to understand the regula- ask educators about energy-enhancing supple-
tions about which medications are allowed in ments they might hear about, the only reasonable
competitive athletics. In addition, there is a answer is: “Don’t use!”. Many supplements have
shared responsibility between the athlete and misleading lists of contents, and some contain
the educator to ensure that any nutritional sup- banned substances. In terms of anti-asthma medi-
plements or herbal preparations do not contain a cations, the oral route is forbidden for all beta-2
banned substance. agonists. Salbutamol, salmeterol, and formoterol
are permitted when given by inhalation. In individuals with triad asthma (asthma with
Terbutaline, orciprenaline, reproterol, and bamb- aspirin sensitivity and nasal polyps), ingestion of
uterol are all banned even when given by inhala- ASA can trigger an acute episode of severe bron-
tion. All inhaled glucocorticoids can be prescribed choconstriction within 20 minutes to 3 hours
without restriction. If systemic corticosteroids [121, 128]. In the respiratory tract, it can also
are required for severe exacerbation, this must be cause rhinorrhea, nasal congestion, and dry
notified to the appropriate authorities. In terms of cough. Non-respiratory symptoms include urti-
the related conditions, such as rhinitis or eczema, caria, angioedema, and hypotension. It can cause
that are similar restrictions on which medications nausea, diarrhea, fatigue, and a sense of malaise.
might be used, efforts might be banned. The edu- It may even cause loss of consciousness and be
cator must always strive to be current in knowl- fatal. One percent of Americans with anaphylaxis
edge of current Olympic regulations. are anaphylactic to aspirin and NSAIDs [123].
There are few elite athletes, of course. See Fig. 8.1.
However, if an educator has the privilege of ASA causes a non-immunologic reaction. It
working with one of these individuals, there is suppresses the production of anti-inflammatory
great satisfaction in helping them deal with exer- prostaglandins and thromboxanes. The cellular
cise symptoms and competing successfully at a metabolism of arachidonic acid involves two
very high level. pathways, the cyclooxygenase (COX-1 and
COX-II) and the lipoxygenase (LOX). Aspirin,
like all NSAIDs, is a cyclooxygenase inhibitor
8.11 Non-asthma Medications [119, 122, 124, 125]. The current hypothesis is
and Asthma that aspirin-intolerant individuals lack a particu-
lar prostaglandin (PG2) which limits the media-
8.11.1 Aspirin Sensitivity tor producing cells [121]. ASA increases the
production of leukotrienes that are known to be
Acetylsalicylic acid (ASA), commonly known as bronchoconstrictors [126], and reactions involve:
aspirin, has been in use for more than a century. A
non-steroidal anti-inflammatory drug (NSAID), it Mast cell activation
was originally prescribed for fevers, but its appli- Increase in neutrophil chemotaxis
cation has widened in recent years. Low-dose Increase in basophil histamine release
aspirin is now used in the prevention of cardiovas- Increase in platelet-activating factor (a potent
cular fatalities and strokes. Aspirin is not well tol- bronchoconstrictor)
erated by everyone, and like the other NSAIDs, it
too can cause problems for those with asthma A detailed history, physical examination, and
(See Figs. 5.1 and 5.2 in Chap. 5). an ASA challenge are required for a diagnosis of
About 5 to 6% of the general population suffer ASA-induced asthma. ASA desensitization can be
from ASA intolerance, with the percentage used in the management of those individuals with
increasing with asthma severity and increasing aspirin-induced asthma, but it does not have a
age [5]. About 10% to 20% of adults with asthma
are ASA and NSAID intolerant [118, 119].
However, the prevalence increases to 30–40% in Reactions to aspirin and NSAIDS include
people with rhinitis and nasal polyps, even in rhinitis dry cough
those without a previous history of ASA intoler- bronchospasm nausea
ance [119]. Aspirin intolerance is common in agniodema diarrhea
adults with asthma [120]. Those persons with urticaria fatigue
aspirin-induced asthma tend to have severe hypotension feeling of malaise
asthma and require high doses of oral or inhaled
corticosteroids [121]. Fig. 8.1 Reactions to aspirin and NSAIDs
major impact on the clinical aspects of asthma • Dysphonia

[121]. Individuals with asthma may also suffer • Contact dermatitis
from myocardial infarction, stroke, and thrombo-
embolic diseases where ASA can be particularly Sulfites are found in:
helpful. Hence, desensitization should not be ruled
out. It can be attempted (under the direction of an • A variety of cooked, processed, and baked
allergy/immunology specialist knowledgeable foods
about the procedure starting with the smallest tol- • Dried fruits, canned vegetables, guacamole,
erated dose), and increasing until 650 mg of ASA and maraschino cherries
does not produce signs or symptoms or cause a • Condiments, jams, gravies, dehydrated or pre-
drop in FEV1. Once desensitization has occurred, cut or peeled potatoes, molasses, shrimp, and
they must continue to ingest at least 325 mg of soup mixes
ASA every day, since discontinuation of ASA • Beverages such as wine, beer, hard cider, fruit
results in the effects of therapy declining in 2 days and vegetable juices, and tea
and being totally lost in 7 days [119, 121]. • The processing of food ingredients including
Individuals with aspirin or NSAID sensitivity beet sugar, corn sweeteners, and gelatin
should be warned to avoid all products that con-
tain them. This can be difficult since many are By law, sulfites may not be used on foods that
not aware of the variety of names under which are meant to be eaten raw such as fruits and veg-
NSAIDs are marketed. Those sensitive to aspirin etables. They cannot be used on fresh produce or
can usually tolerate acetaminophen and non- in restaurant salad bars. Sulfites are used to pre-
acetylated salicylates such as salsalate and vent oxidation or browning in fruits and vegeta-
sodium salicylate. If there is any doubt, they bles, control microbial growth, prevent
should check with their healthcare provider or decomposition, preserve flavor, prevent spoilage,
pharmacist, particularly since not only over-the- condition dough, bleach food starches, and stabi-
counter medications but also many prescription lize and maintain the potency of medications.
medications contain NSAIDs. Food manufacturers and processors are legally
required to disclose the presence of sulfiting
agents in concentrations of more than 10 ppm
8.11.2 Sulfite Sensitivity (parts per million). Regardless of the amount
present, sulfites must be listed if they are used as
Symptoms of sulfite sensitivity include asthma, a preservative or for certain functions in food
urticaria, angioedema, abdominal pain, nausea, such as conditioning dough. Standardized foods
diarrhea, seizures, and anaphylactic shock result- such as pickles and bottled lemon juice must list
ing in death [127, 128]. Levels as low as 1 part sulfites on the label.
per million can trigger asthma. Symptoms also The US Food and Drug Administration (FDA)
include [129, 130]: lists six sulfiting agents as GRAS (generally
regarded as safe). These include sulfur dioxide;
• A severe respiratory reaction sodium sulfite; and both the bisulfites and metabi-
• Flushing sulfites of sodium and potassium. Efforts have
• Feeling of temperature change been made to rescind the status of GRAS on sul-
• Onset of hypotension fited foods such as frozen potatoes, but the food
• Vomiting industry has countermanded every effort to date.
• Difficulty swallowing Current FDA regulations do not require food ser-
• Dizziness vice establishments to indicate whether sulfites
• Urticaria were used in the food preparation.
• Nasal itching Generally, sulfite sensitivity is found in per-
• Rhinorrhea sons with asthma who are steroid dependent
[130, 131]. In steroid-dependent children, the of surrounding tissue. Antihistamines block the
prevalence has been found to be 20% [132]. effect of released histamine and hence reduce the
Reactions to sulfites can vary from mild to severe severity of symptoms.
and even fatal bronchospasm in about 5% to 10% Histamine causes a number of responses in
of individuals with asthma [133–135]. different tissues and cells. It:
It should be noted that bisulfites can cause
bronchoconstriction in persons with asthma and Is an important mediator of inflammation
that sensitivity to bisulfites increases with age Causes smooth muscle contraction in both the
[136]. Sulfite sensitivity has also been linked to respiratory and gastrointestinal tracts
atopy. It is generally not found in persons who Stimulates sensory nerves to cause itching and
are both nonatopic and non-asthmatic [137]. sneezing
Even in those who are sensitive to inhaled sul- Causes low blood pressure, flushing, and head-
fites, the ingestion of sulfite-containing foods ache and speeds up the heart
may not cause a reaction since the reaction
depends on a number of factors including the The histamine antagonists are of two types:
sensitivity of the individual, the nature of the H1, which acts on the respiratory tract, and H2,
food, the level of sulfite, the form of the residual which acts on the gastrointestinal tract. In aller-
sulfite, and the mechanism by which sulfite gic diseases, H1 antagonists are used, and they
engenders a reaction [138]. Ingestion of may conveniently be divided into two groups,
sulfite-
containing foods followed by topical depending on the year of their introduction and
application of cosmetics containing sulfite can the likelihood of drowsiness:
result in skin reactions [130].
Some asthma medications have sulfites in First generation, in which sedation is common.
them. Sulfite can trigger bronchospasm in a dose- Second generation, in which sedation is uncom-
related manner. For instance, both isoproterenol mon. These include most antihistamines intro-
and isoetharine contain sulfite in sufficient dos- duced since 1981. See Table 8.3.
age to trigger bronchospasm in most individuals
with asthma. They can also give rise to broncho- Antihistamines are generally used as “rescue
spasm in those people with asthma who are not medications”—to initially counteract and then to
sulfite sensitive [139]. prevent the effects of an allergic reaction. The
Sulfite sensitivity should not be confused with resulting effect of taking an antihistamine, the
sulfates or with sulfur drugs. time it takes to reach peak effect, and the duration
of the effect all depend on the dose ingested.
Most people reach for an antihistamine when
8.11.3 Antihistamines pollen season begins. Yet, antihistamines are
most effective if started before pollination begins
Antihistamines, which suppress the symptoms and if used regularly during the pollen season.
that result from an allergic reaction, are among They are not effective for the treatment of upper
the most widely used medications in the world. respiratory tract infections.
They are commonly used by individuals with
asthma to treat associated conditions such as rhi- 8.11.3.1 Adverse Effects
nitis. It is debatable if they have any effect in of Antihistamines
asthma [125] and thus are not used in its treat- First-generation antihistamines affect the central
ment. They do not affect the inflammation under- nervous system [140–145]. They cause sleepi-
lying an asthma attack. ness, reduce alertness and reaction time, affect
During an allergic reaction, the body releases coordination, and, since they cross the blood-
histamine, among other chemicals. Histamine brain barrier, reduce ability to think logically and
has many effects, chief of which is inflammation to concentrate. They can also cause gastrointesti-
Table 8.3 Antihistamines
Antihistamines
Generic name Trade name Formulation
First generation
Chlorpheniramine Chlor-Trimeton Tablets/syrup
Diphenhydramine Benadryl Capsules/elixir/syrup
Hydroxyzine Vistaril, Atarax Capsules/syrup
Second generation
Acrivastine Semprex Tablets
Azelastine Astelin Spray
Bilastine Bilaxten, Blexten Tablets
Cetirizine HCL Zyrtec, Reactine Tablets
Levocabastine Livostin Spray
Levocetirizine Xyzal Tablets
Loratadine Claritin, Alavert Tablets
Rupatadine Rupall Tablets
Third generation
Desloratadine Clarinex, Aerius Tablets
Fexofenadine Allegra Capsules/foil/blister packs
nal upset, stimulate the appetite, and produce dry to be both more effective, have quicker onset of
mouth, blurred or double vision, confusion, diz- action, last longer, and are safer [145]. Both
ziness, fatigue, tinnitus (ringing in the ears), uri- orange and grapefruit juice reduce the bioavail-
nary retention, constipation, and sometimes ability of fexofenadine, and individuals should be
impotence. They may also cause euphoria, irrita- advised to wait for 4 hours between drinking
bility, nervousness, restlessness, and nightmares. these juices and taking fexofenadine.
The adverse reactions depend on the medication
taken. An overdose of these medications may 8.11.3.2 Excipients
produce coma, seizures, hallucinations, heart An excipient is an inert substance in a medication
block, tachycardia and arrhythmias, respiratory that is used in manufacturing for a number of rea-
depression, and death. sons, including protecting stability, improving
First-generation antihistamines are still used bioavailability, or improving the flavor.
because they are both effective and inexpensive. Antihistamines may have sweeteners, flavorings,
Individuals should be warned not to drive or to dyes, and preservatives in them. Reactions to
undertake complex tasks while on these medica- antihistamines may be caused by these excipients
tions: the sedative effects and drowsiness they and other inert ingredients added during their
can cause can be lethal, for example, when driv- manufacture. It should be noted that:
ing. These drugs affect attention, memory, and
sensory-motor performance. They have also been Sweeteners include glucose, lactose, mannitol,
associated with reduced school performance. saccharin, sorbitol, sucrose, and vanillin
Second-generation antihistamines also affect Flavorings are considered trade secrets and can
the nervous system, though they have fewer side be any 1 of the 38 different flavors derived
effects than the first generation. Headache is the from a variety of sources including natural fla-
most common side effect, with somnolence also vors, essential oils, and synthesized
reported [146]. Generally, the advantage of these fragrances
antihistamines is that they are less likely to have The most common preservative used is sodium
a sedating effect; on the other hand, however, benzoate, while Yellow #6 and Red #40 are the
they are much more expensive. most common dyes
Third-generation antihistamines are metabo- All antihistamines except hydroxyzine syrup
lites of previously available medication and tend contain corn starch and coloring
8.11.4 Over-the-Counter Failure to realize that OTC medications increase

Medications the risk of drug-drug interactions [149]
Disregarding evidence that shows a lack of effi-
The prevalence and availability of over-the- cacy or adverse effects for some OTC medica-
counter (OTC) products has increased so dramat- tions [150]
ically that by the year 2002, over 100,000
products were available, not only in pharmacies OTC medications are often used because of
but also in supermarkets, drug stores, conve- cost, convenience, value of time, and the percep-
nience stores, and gas stations. This ease of tion that the price provides value for money. OTC
access has resulted in a casual and nonchalant products are known by brand name and not by the
attitude toward OTC medications. The majority active ingredient. Advertising, with its emphasis
of OTC medications have the same basic on self-care, has a major impact on sales of
ingredients: deregulated medications [151].
Those at risk from OTC medications include
Decongestants the very young, older adults, competitive ath-
Antihistamines letes, pregnant women, nursing mothers, those
Antitussives taking multiple medications, and those with pre-
Expectorants existing conditions such as asthma, diabetes,
Analgesics impaired renal function, cardiovascular disease,
coagulation defects, and gout.
Combination products may have anywhere The major classes of OTC medications are
from two to four active ingredients (36% and antacids, antihistamines, NSAIDs or non-
11% of all OTC medications, respectively) [147]. steroidal anti-inflammatories, cough and cold
The FDA, which regulates OTC medications, preparations, and anti-asthma medications. Many
has strict criteria for deregulation of prescription of the OTC medications contain antihistamines
medicines. The FDA requires that there be a low and/or decongestants. Sleep medications also
risk of side effects at therapeutic doses; that contain antihistamines and decongestants so that
adults be able to self-diagnose and select the individuals may unknowingly consume an unsafe
appropriate treatment; and that the medication be dose. Individuals with asthma should avoid OTC
so labeled that the average person can read and products for insomnia.
understand the indications, contraindications, Everyone should know that antacids affect the
and directions for its use. absorption and excretion of prescribed medica-
OTC medications are real medications that tions [152]. The antitussives in use are either
offer many benefits. While they are safe if used codeine or dextromethorphan. The latter is fairly
correctly, there are unfortunately a number of safe and does not cause the stomachache and
factors that inhibit their safety. They include: drowsiness that is associated with codeine.
Codeine affects the central nervous system and is
The perception that OTC medications are not not recommended for children [153]. The antitus-
“real” medicines sives are not recommended for children with
A lack of understanding about ingredients asthma. The commonly used expectorant is guai-
Inability to read and understand product labeling fenesin which is thought to thin bronchial secre-
Incorrect calculation and measurement of an tions to produce a more productive cough. This
appropriate dose view is not supported by the current medical
Inability to correctly self-diagnose literature.
Failure to inform the healthcare provider of OTC Among the decongestants, pseudoephedrine,
medications being taken [148] ephedrine, epinephrine or adrenalin, and phenyl-
Unrealistic expectations about the medication’s ephrine hydrochloride are commonly used in
ability to relieve symptoms short-acting decongestants. With pseudoephed-
rine, the range between a therapeutic and a toxic includes many patients with asthma. NSAIDs
dose is very narrow. Pseudoephedrine affects the inhibit the enzymatic activity of cyclooxygenase
central nervous system (CNS), causing appetite and interfere with the synthesis of prostaglan-
suppression, nervousness, dizziness, sleepless- dins. They can be grouped into salicylate, propi-
ness, palpitations, hypertension, hyperglycemia, onic acid derivatives, naproxen sodium,
and urinary retention. In children, it has been aminophenol, and ketoprofen. A study on the
known to cause irritability, hallucination, hyper- relative risk of serious upper gastrointestinal
tension, and hyperactivity. In the older adult, it complications varied from a low for ibuprofen
elevates blood and intraocular pressure and wors- and diclofenac; to medium risk with sulindac,
ens urinary obstruction. It interacts with many naproxen, and indomethacin; to high risk with
medications including beta-blockers. piroxicam and ketoprofen [156]. Individuals tak-
Pseudoephedrine is contraindicated for anyone ing NSAIDs increase their risk of gastrointestinal
taking prescription medications for depression bleeding by a factor of 3 when compared with
and/or high blood pressure [154]. those who do not use them. NSAIDs increase the
Ephedrine is a common anti-asthma OTC risk of formation of esophageal stricture and
medication that poses a greater chance of causing cause edema and weight gain, thus adversely
adverse drug effects or drug interactions than epi- affecting the kidneys and indirectly affecting the
nephrine because it must be absorbed into the cardiovascular system. They increase blood pres-
body to be effective. Nervousness, sleeplessness, sure and interfere with blood pressure medica-
anxiety, nausea, reduced appetite, rapid heart- tions. High doses of NSAIDs for a lengthy period
beat, tremors (the “shakes”), and urinary reten- of time can induce stomach pain, bleeding from
tion are the most common adverse effects, and gastritis or ulcers, and even kidney failure. In
immediate medical attention may be necessary some individuals, topical use can cause itching,
for these. Ephedrine is a stimulant that is used rash, and eczema.
both as a decongestant and as a bronchodilator. In pregnancy, the FDA warns against the use
Overuse results in insomnia, nervousness, and of NSAIDs around or after the 20th week of preg-
tremors. Repeated use builds tolerance so that nancy since such use may have a detrimental
more of it is required for relief. It can elevate effect on the fetus.
heart rate and blood pressure. It affects glucose Among older adults, OTC medication use
levels and may cause urinary retention [153]. costs half as much again as prescription medica-
When combined with a prescribed monoamine tions [157], and they use them for symptoms that
oxidase (MAO) inhibitor, it can cause potentially are considered non-threatening [158].
fatal hypertension [154]. It should not be taken The most commonly used OTC medications
by persons with heart or thyroid disease, diabe- in the older adults are analgesics, vitamins, topi-
tes, or high blood pressure. cal skin products, antacids, laxatives, cold and
OTC anti-asthma medications are of concern cough products, and topical analgesics, in that
when used by individuals to treat their asthma. order [154]. Older adults are particularly at risk
Many anti-asthma medications contain theophyl- for self-medication for they tend to suffer from
line, which has a very narrow safety zone [155]. concomitant diseases. In individuals over the
Patients need careful monitoring in order to age of 65, 78% have at least one chronic dis-
maintain a therapeutic dose and avoid toxic side ease, while 10% may have as many as three or
effects. OTC bronchodilators interact with pre- more chronic diseases. Adverse drug reactions
scription medications for both high blood pres- and interactions are more common in the older
sure and depression. Many OTCs contain aspirin adult [159].
but are not clearly labeled as such. OTC medications are used by people of all
NSAIDs are contraindicated for anyone with ages [160]. Studies have found that most indi-
specific sensitivity to these drugs, and this viduals could not identify precautions associated
8.12 Direct-to-Consumer Advertising (DTCA): Advantages and Disadvantages 283
with the medications they were taking [157, 161]. 8.12 Direct-to-Consumer
One study found adolescents who regularly took Advertising (DTCA):
aspirin for stomachache were unaware that aspi- Advantages
rin irritates the lining of the stomach [161]. and Disadvantages
OTC medications are safe and effective when
used in accordance with the manufacturer’s As mentioned earlier in this chapter, DTCA is a
directions. They should not be taken with alco- reality in the USA and in New Zealand, although
hol. They should be: the latter may soon ban theses advertisements
[165]. The idea is not new and extends back to at
• Used to provide temporary relief of minor least the nineteenth century. Those supporting
symptoms DTCA claim this leads to a more informed pub-
• Taken only at the recommended dosage for lic—people can explore many treatment options
the recommended length of time for their healthcare concerns, and there is no need
• Avoided by pregnant and nursing mothers to rely on a healthcare provider for information.
• Taken with care by individuals with chronic Some physicians have noted that, in discussions,
health problems and allergies patients exposed to DTCA are more thoughtful in
their questions [166]. There is speculation that
The ingredients in OTC medications can DTCA may reduce under-diagnosis of some con-
change from time to time. Users should check for ditions, reduce stigma, and encourage adherence
any changes each time they make a repeat pur- to current treatments. Others argue that DTCA
chase of a medication. increases clinically inappropriate prescriptions.
OTC medications come with information Physicians will accommodate patient preferences
leaflets. However, a study of 50 leaflets by by filling DTCA-triggered prescriptions, even if
Bradley and others found that the leaflets were these are not warranted [167].
too difficult for the intended audience [162] Formal regulation of DTCA has existed in the
being generally at a literacy level higher than USA since at least 1969. The regulations were
that of the average adult. Furthermore, there was relaxed in 2004, allowing a “simplified brief sum-
no research-based source to enable consumers mary” [168]. This means that only “major risks”
to judge the quality of the information provided need be presented and simplified language used in
[163]. advertisements, which allows pharmaceutical
Because many people do not regard OTC preparations to be presented in a very positive
medications as “real” medications and do not light. In light of this, it is worth noting that a
appreciate the risks involved, they may not tell Cochrane review concluded that the underlying
their healthcare providers that they use these literature, if sponsored by a manufacturer, “leads
products. They will maintain a false sense of to more favorable efficacy results and conclusions
security about OTC medications and may not than sponsorship by other sources” [169].
see the purpose of informing the health profes- In the comment referenced above [168], points
sional. It behoves the asthma educator to ask are made that are directly relevant to new anti-
them if any OTC medications are being used asthma preparations, especially ones such as
and to ensure that they understand the risks monoclonal antibodies that are, and will be, expen-
associated with them. Pharmacists are often sive. These points are that DTCA advertising:
regarded as knowledgeable about medications,
and invoking their help or reminding individuals • Misinforms patients
to check with the pharmacist may help them • Overemphasizes drug benefits
avoid the inherent dangers in OTC medications • Promotes new drugs before safety profiles are
[164]. fully known
• Manufactures (or “invents”) disease and 2. Schatz M, Dombrowski MP, Wise R, Thom EA,
Landon M, Mabie W, et al. Asthma morbidity during
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People with asthma will see advertisements logic treatment. Update 2004. NIH Publication No.
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a particular product is suitable for them. Some, 5. National Asthma Education and Prevention Program
however, will demand a prescription for a new Expert Panel Report 3. Guidelines for the diagno-
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Comorbidities in Asthma
9
Contents
9.1 Comorbidities and Their Treatment 292
9.2 Contact Dermatitis 292
9.3 Atopic Dermatitis and Eczema 293
9.4 R
hinitis, Sinusitis, and Rhinosinusitis 293
9.4.1 Rhinitis 293
9.4.2 Sinusitis 297
9.5 Nasal Polyps 299
9.6 Gastroesophageal Reflux 299
9.7 Vocal Cord Dysfunction (VCD) 302
9.8 Asthma-COPD Overlap (ACO) 304
9.9 Obstructive Sleep Apnea 305
9.10 Bronchopulmonary Aspergillosis (ABPA) 307
9.11 Depression 309
9.12 Acute, Severe Acute, and Life-Threatening Asthma 310
9.12.1 Classification of Severity of Acute Asthma 312
9.12.1.1 Assessing an Attack 315
9.12.1.2 The Life-Threatening Attack 316
9.12.2 Treating Asthma in the Home 316
9.12.3 Treating Asthma in the Office 317
9.12.4 Cardiopulmonary Resuscitation (CPR) 318
9.13 Anaphylaxis: Type 1 Allergy 318
9.13.1 Definition 318
9.13.2 Causes 319
9.13.3 Risk Factors for Anaphylaxis 321
9.13.4 Symptoms 321
9.13.4.1 Biphasic Reactions 321
9.13.5 Differential Diagnosis of Anaphylaxis 322
9.13.6 Management of Anaphylaxis 322
9.13.7 Education for Anaphylaxis 323
References 324
292 9 Comorbidities in Asthma
9.1 Comorbidities and Their

Key Points Treatment
• Asthma control is greatly affected by Individuals with asthma commonly have other
common comorbidities. allergic conditions [1, 2]. In children, asthma,
–– Some are allergic disorders such as along with other conditions such as autism, atten-
of rhinitis, atopic and contact derma- tion deficit hyperactivity disorder, and obesity, is
titis, and allergic bronchopulmonary becoming more prevalent [3]. Blackman and
aspergillosis. Gurka noted that children with asthma have
–– Some are not allergic, such as sinus- higher rates of attention deficit hyperactivity dis-
itis (may be partly allergic), gastro- order, depression, behavioral disorders, and
esophageal reflux, vocal cord learning disabilities. The more severe the asthma,
dysfunction, COPD and the asthma- the higher the number of these problems. Even
COPD overlap, depression, and when adjusted for socioeconomic factors, having
obstructive sleep apnea. asthma significantly increases the odds of behav-
• Attacks of asthma vary in severity and ioral, emotional, and developmental problems
implication. [4]. Effective asthma management means that all
–– Depending on assessment, they may related/coexistent conditions must be well
be treated at home, in a clinic. or in managed.
an emergency department.
• Anaphylaxis is a severe version of
allergy. 9.2 Contact Dermatitis
–– We discuss the risk factors, causes,
symptoms, differential diagnoses, This is a delayed hypersensitivity or cell-
and management to education. mediated immune reaction in the skin. Reactions
can occur on any mucous membrane, but most
cases occur on the hands. However, the hands can
transfer offending agents to secondary body sites.
Chapter Objectives There is redness progressing to blistering and
weeping and intense itch, but all confined to the
areas of skin in contact with an agent that can be
able to:
an allergen or an irritant [5].
In allergic contact dermatitis, cutaneous reac-
• List those medical conditions that are
tions may occur anywhere from 24 to 48 hours
often associated with asthma and their
after exposure to the allergen with accompanying
treatments.
pruritus.
• Classify, assess, and treat an asthma
Common “offenders” are fur, fragrance
attack in the home, clinic or office.
chemicals, leather and fabric dyes, nickel, rub-
• List the risk factors and symptoms of
ber (latex), and poison ivy. Household cleaners,
anaphylaxis and explain its biphasic
antimicrobials, detergents, and topically
nature and its causes.
applied products, such as creams, soaps, per-
• List the other medical conditions that
fumes, sunscreens, hair dyes, medications, cos-
can be misdiagnosed as anaphylaxis.
metics, etc., are also common causes of irritant
• Demonstrate the use of an epinephrine
contact dermatitis.
injector.
The severity of both allergic and irritant-induced
contact dermatitis is determined by the [4]:
9.4 Rhinitis, Sinusitis, and Rhinosinusitis 293
• Nature of the offending substance 9.3 Atopic Dermatitis

• Strength and duration of exposure and Eczema
• Location of exposure
• Condition of exposed body part Atopic dermatitis affects 20% of children and
• Hydration status of the skin about 3% of adults. It includes infantile eczema,
with rash, dryness, and itching on any part of the
The most common allergen in hair dyes is body. In adults, it tends to be present in a number
p-phenylenediamine or PPD. It is an ingredient of sites, including the flexures (inside elbows and
with high temperature stability, strength, and behind knees), and in patches anywhere on the
chemical resistance. For this reason, it is used in skin. Lesions vary from some redness and mild
textiles, fur-dyeing, dark-colored cosmetics, rub- scaling to frank oozing and “weeping”. In long-
ber chemicals, engineering polymers and com- standing cases, the skin may be thickened
posites, plastics, photocopying and printing, (lichenified). Itch is the most distressing accom-
black rubber, oils, greases, gasoline, pigments, paniment; scratching can lead to perpetuation of
and hair dyes. In North America, it is estimated the eczema, secondary infection, and scarring.
that between 40% and 75% of women and girls Recommendations include neutral soap for
dye their hair, and the number of men and boys individuals with dermatitis, oil whenever there is
who dye theirs is increasing. This is not restricted a bath, and use of a moisturizing lotion after bath-
to North America. It is an increasing problem ing. Topical corticosteroids are used, similar to
worldwide. those used in asthma. It is important not to use
Tattoos are increasingly popular in body art. topical corticosteroids on the face unless under
When henna, the dried powdered leaf of Lawsonia close medical supervision. Protopic (tacrolimus),
inermis, is used, it colors the skin reddish-brown an immunosuppressant ointment, has had excel-
and wears off in time. Because PPD increases lent results. Antihistamines may be very useful in
both the intensity and longevity of a dye, it is controlling itching. Careful choice of laundry
combined with henna and used in tattoos. Women detergents may be necessary. Extra rinsing of
who have had temporary tattoos can become sen- washed clothing and avoidance of scented fabric
sitized with subsequent exposure causing a softeners will also be helpful.
delayed Type IV hypersensitivity resulting in In infants, diet may be important. Many
acute contact dermatitis. Cross-reactions to other healthcare providers will try dietary changes to
hair dyes or those used in textiles and rubber obtain control of the eczema.
products can also occur. While a detailed management of eczema is
A study by Sosted and colleagues of 2939 outside the scope of this text, the professional
patients in 12 dermatology clinics found a pos- should know the basics about this skin condition
itive reaction to PPD in 4.5% of patients. The that commonly coexists with asthma.
most frequently reported cause of allergy in
55.4% was hair dye with 8.5% of the cases as a
result of the use of temporary henna tattoos 9.4 Rhinitis, Sinusitis,
[6]. and Rhinosinusitis
Contact dermatitis is the most common occu-
pational disease, accounting for 90% of occupa- 9.4.1 Rhinitis
tional skin disease and between 30% and 40% of
all occupational illnesses. Once the condition is Allergic rhinitis (AR) is the most common
recognized, contact with the offending substance chronic disease associated with asthma and
must cease. A steroid cream may be required for affects 20–40% of the population in North
a short time. America [7]. Among children, the prevalence is
up to 40% [8], while with adolescents, the preva- When compared with individuals with asthma,
lence is 30% [9] to 50% [10]. Worldwide, AR they have a lower quality of life. A study in
affects from 5% to 50% [10–12]. Among those California examined adults between the ages of
with asthma, the percentages are much higher, 18 and 50, 125 of whom had asthma only and 175
ranging from a low of 58% [9] to an upper figure of whom had rhinitis alone. Both asthma and rhi-
of 78% [13]. It should be noted that the incidence nitis affected work productivity. Those with
of exercise-induced asthma is about 40% in those asthma were less likely to be employed than
with AR [14]. those with rhinitis; for those who were employed,
Asthma is of more concern than rhinitis to however, rhinitis affected productivity more than
most clinicians, and attention is most often paid did asthma [26].
to the symptoms of asthma, with those of rhinitis Allergic rhinitis has been defined by the World
being neglected. However, there is a link between Health Organization (WHO) as an “aller-
rhinitis and asthma, and inflammation of the gen‑induced inflammation of the membranes lin-
upper airways contributes to hyperresponsive- ing the nose. Based on time of exposure to the
ness and symptoms in the lower airways [15]. allergen, allergic rhinitis can be subdivided into
More importantly, treating rhinitis often improves perennial, seasonal or occupational disease” [27].
both the symptoms of asthma and pulmonary Allergic rhinitis is often connected with
function [9, 16]. eczema, food allergy, and asthma—this is known
The symptoms of rhinitis include rhinorrhea, as the allergic march.
nasal congestion, sneezing, and pruritus of the
ears, nose, and throat. They can also include:
Case Study
• Mouth breathing
• Snoring Jane Jones brings her 6-month-old son Ken
• Difficulty in eating (nursing in infants) to see you. Ken has extensive infantile
• Itchy, tearing, and red or bloodshot eyes eczema and has been assessed by the fam-
• Persistent sneezing ily healthcare provider and by a dermatolo-
• Nasal speech gist. He is doing well on a complex regimen
• Inability to clear the nose of moisturizing cream, corticosteroid
cream, and a restrictive diet. Jane’s sister
Nasal itching leads to constant nose rubbing has told her that Ken might get asthma and
(the so‑called “nasal or allergic salute”) resulting that he should not go to day care because of
in the telltale crease across the nose. Nonnasal the risk of frequent colds and flu. She asks
symptoms include headache, thirst, and disturbed you for advice on whether there really is a
sleep [9, 16–21]. risk of asthma and, if there is, how to pre-
When there is severe rhinitis and a history of vent it. How will you respond?
snoring, obstructive sleep apnea (OSA) is possi- Eczema, allergic rhinitis, and asthma are
ble. The educator should suggest to the individual part of the group of allergic disease so that
that they discuss this possibility with the he is at increased risk of asthma. Diet is
healthcare provider. important in the development of eczema
Rhinitis affects productivity, learning, and and inhaled allergens and irritants in the
concentration [13, 22]. Chronic rhinitis has been development of asthma. You need to go
linked to depression, fearfulness, fatigue, cogni- over the important inhalants such as
tive and mood impairments, poor psychological tobacco smoke, pets, and molds. Does Ken
adjustment, and inability to handle environmen- have siblings? If so, he will have more trou-
tal pressures [17, 23, 24]. Perennial rhinitis ble early with colds but may do better in the
impairs the quality of life in persons with moder- long run. The same response can be given
ate to severe rhinitis [17–25].
Allergic rhinitis usually develops during

to the question of day care, but in this situ- childhood. Sensitization can be limited by reduc-
ation, the frequency of infection might be ing exposure to household allergens and by pay-
too high to risk, and a day home with 1–3 ing attention to food allergies during infancy and
children might be a better option. If Ken early childhood [8]. The most common allergens
does start to wheeze, the treatment should that trigger rhinitis are house dust mites, animal
be aggressive and should start early. dander, pollens (grass, trees, and weeds), cock-
Although inhaled corticosteroids have not roaches, molds, and, rarely, aspirin and other
been extensively studied in this age group, nonsteroid anti‑inflammatories drugs (NSAID)
most pediatric asthma specialists would [16, 27]. Both sensitization to pollens and pets
prescribe them. are considered risk factors for the onset of AR
[24, 31]. However, when combined with
sensitization to pets and tobacco smoke, AR is a
AR is underestimated as a cause of suffering risk factor for the onset of asthma [31]. In many,
and reduced quality of life in children and adoles- rhinitis precedes the development of asthma, and
cents [22]. Juniper found that those with AR are those with rhinitis are more likely to develop
often tired and exhausted during the day and are asthma [32]. This is particularly true of individu-
unable to sleep well at night [28]. They experi- als with occupational rhinitis who, over time,
ence decreased alertness, reduced concentration, develop occupational asthma [33].
lower productivity, mood changes, cognitive dis- Rhinitis or allergic rhinitis is diagnosed
turbances, and limitations in daily activities. through a detailed history of symptoms, physical
Allergic rhinitis affects daily living, emotional examination, and diagnostic testing that may
function, and sleep as well as the quality of life include anterior rhinoscopy and/or skin prick
[23]. testing [20, 27]. The WHO Initiative on Allergic
Rhinitis and asthma are both allergic disor- Rhinitis and its Impact on Asthma (ARIA) has
ders, and it is no surprise that they are commonly changed the classification of “seasonal” and
found together in one individual. However, there “perennial” allergic rhinitis to “intermittent” and
is suggestive evidence that rhinitis is more than a “persistent” allergic rhinitis respectively, each
companion of asthma; it may well be a significant with subcategories of mild, moderate and severe.
risk factor for asthma. In both atopic and non- Asthma is associated with both perennial and
atopic individuals, rhinitis increases the risk of seasonal rhinitis, and both these conditions can
developing asthma threefold. For those with high influence the severity of asthma [15, 23].
levels of IgE, the risk is increased by a factor of Treatment of allergic rhinitis is comprised of
five [29]. A diagnosis of rhinitis in infancy dou- avoidance of allergens where possible, pharma-
bles the odds of developing asthma by the age of cology and immunotherapy [15, 16, 20, 34].
eleven [23]. It has been noted that in individuals Pharmacology therapy includes the use of decon-
with asthma, 75% have allergic asthma, while gestants, antihistamines, and intranasal or oral
more than 80% of those with nonallergic asthma corticosteroids [15, 27, 35]. See Table 9.1.
have seasonal or perennial rhinitis [16]. In an Antihistamines are the first line of treatment.
American study that involved 4944 persons who For those individuals who have trouble sleeping,
suffered from both AR and asthma, 73% of the a combination of nonsedating antihistamine in
participants were treated for AR. The treated the morning and a sedating antihistamine at night
group had less asthma-related events and a sig- is recommended [20]. Many of the first-
nificantly lower risk for emergency department generation antihistamines used to treat rhinitis
visits and hospitalizations than the untreated may affect the central nervous system and cause
group [30]. The inescapable conclusion was that adverse effects that contribute to learning impair-
allergic rhinitis is an important risk factor for ment [22]. Intranasal antihistamines are preferred
asthma [18, 27]. since they have a rapid onset of action and reduce
Table 9.1 Medications for Type Generic name Trade name

the treatment of rhinitis Oral antihistamine Fexofenadine Allegra
hydrochloride
Loratadine Alavert, Claritin (tablets,
Desloratadine Reditabs, syrup)
Clarinex (tablets), Aerius
Cetirizine Reactine, Zyrtec
Levocetirizine Xyzal
Bilastine Bilaxten, Blexten
Rupatadine fumarate Rupall
Oral nonsedating Fexofenadine/ Allegra-D
antihistamine- pseudoephedrine
decongestant Loratadine/ Claritin D (12 and 24 hours)
combinations pseudoephedrine
Acrivastine/ Semprex-D
pseudoephedrine
Intranasal antihistamines Azelastine hydrochloride Astelin
Levocabastine Livostin
hydrochloride
Intranasal mast cell Cromolyn sodium NasalCrom
stabilizers
Intranasal Ipratropium bromide Atrovent
anticholinergics
Intranasal corticosteroids Beclomethasone Beconase, Beconase AQ,
dipropionate Vancenase, Vancenase AQ
Budesonide Rhinocort
Ciclesonide Omnaris
Fluticasone propionate Flovent, Flonase
Fluticasone furoate Avamys
Mometasone furoate Nasonex
Fluticasone azelastine Dymista
Triamcinolone acetonide Nasacort, Nasacort AQ
Leukotriene inhibitor Montelukast Singulair (Black Box
warning)
symptoms in eyes and throat. They are not effec- ment should begin about 2 weeks before the onset
tive for treating nasal congestion (see section on of symptoms and continue for 2–3 weeks after
Antihistamines in Chap. 8). the season. For those with severe symptoms, a
Decongestants are used to treat nasal conges- short 3‑ to 7‑day course of oral corticosteroids
tion. The side effects include hypertension, rest- may be required to control the exacerbation.
lessness, tremor, agitation, insomnia, headache, Cromolyn is effective in blocking both the
dry mucous membranes, urinary retention, car- early and late phase responses. However, to be
diovascular effects, and glaucoma. Intranasal truly effective, it should be used prophylactically
decongestants are very effective, but repeated use four to six times a day [20]. Ipratropium bromide
may cause a rebound phenomenon, whereby the increases the ability of the nose to condition cold,
congestion and edema worsen. dry air [24], and it significantly reduces rhinor-
Corticosteroid nasal sprays are very effective, rhea [25]. Leukotriene modifiers have shown
reducing both the symptoms of asthma and lower some success in treating allergic rhinitis, but
airway hyperresponsiveness [9]. The side effects more evidence is required before they become an
include stinging, burning, sneezing, nosebleeds, integral part of the treatment regimen [23,
and dryness. For seasonal allergic rhinitis, treat- 34–37].
Immunotherapy has been successful in treating Early treatment and management of allergic rhini-
allergic rhinitis [23]. For individuals with allergic tis is essential [13]. Treatment of the symptoms of
rhinitis, specific immunotherapy can decrease air- rhinitis should be part of any asthma management
way hyperresponsiveness [16, 24, 38, 39]. plan. Individuals with asthma should be examined
Immunotherapy should be considered when [20]: for allergic rhinitis, and those with allergic rhinitis
should be examined for asthma [27].
• The allergen season is long. Chronic rhinitis may also lead to obstructive
• The person has perennial symptoms. sleep apnea (OSA), and treating the rhinitis may
• The person does not tolerate or respond to improve the OSA [41]. Formal sleep studies (poly-
medications or is unwilling to use them. somnography, PSG) may be needed in some
• The person has asthma that is worsening. instances to delineate the severity of the OSA. Also,
• The person has chronic or recurrent rhinosi- the advice of an otolaryngologist (ENT surgeon)
nusitis/middle ear disease. should be sought in severe persistent rhinitis.
The management of allergic rhinitis should

include these four components [38–40]: 9.4.2 Sinusitis
1 . Avoidance of allergens Sinusitis affects up to 14% of Americans [42] with

2. Appropriate pharmacology 37 million experiencing at least one episode each
3. Evaluation for immunotherapy year [43–45]. Allergy is a contributing factor in as
4. Education and follow-up many as 25–28% of them [45]. Sinusitis is an infec-
tion of the nasal sinuses. It is a complication that can
A nonallergic form of rhinitis known as vasomo- result from upper respiratory infections, nasal pol-
tor rhinitis also exists, and its major symptoms are yps, and other types of nasal obstruction [16], and it
nasal blockage and rhinorrhea. The etiology is is also a common complication of allergic rhinitis
unknown and it is hard to treat. The asthma educator [46]. Rhinitis generally precedes sinusitis, and sinus-
has a role to play in educating the person, both on itis without rhinitis is rare [42]. Sinus inflammation
how to take their medications and on how to avoid that occurs with rhinitis is labeled rhinosinusitis
or minimize contact with allergens. Suggestions for (RS). For that reason, the descriptor rhinosinusitis
nonpharmacologic treatments to reduce discomfort (RS) will be used much more than sinusitis by itself.
can be offered. These include [20]: There are a number of predisposing factors to
sinusitis and RS [20, 44, 46, 47]. Local factors
• Nasal lavage with warm salt water (with or include:
without baking soda).
• Inhalation of warm mist through the nose, for • Upper respiratory infections (usually viral)
10–15 min, 2–4 times a day. • Allergic rhinitis
• Nonallergic rhinitis
It is also important to verify what treatments • Overuse of topical decongestants
they are using. The use of alternative treatments • Hypertrophied adenoids
must be explored and discussed. A California • Deviated nasal septum
study of 300 adults aged 18–50 years, all with a • Nasal polyps
diagnosis of asthma or rhinosinusitis, found that • Tumors
42% used alternative treatments that included • Foreign bodies
herbs, caffeine, homeopathy, acupuncture, aro- • Swimming and diving
matherapy, reflexology, and massage, and 26% • Smoking cigarettes
did not use prescription medication [9]. • Cocaine use
Since allergic rhinitis and asthma can and do • Dental disease
coexist, it is important to treat both conditions. • Gastroesophageal reflux disease
Sinusitis symptoms include nasal congestion, The mainstay of management is humidifica-

postnasal drip, rhinorrhea, headache, facial pres- tion, nasal rinse, and decongestants. Decongestants
sure/pain, cough, throat clearing, and a dimin- need to be used cautiously and only for short peri-
ished sense of smell [42, 43, 47–50]. Fever is not ods, perhaps for 3 days or so. If the prescriber is
always present. Nocturnal cough (also a symp- unfamiliar with the choice of decongestants,
tom of asthma) is a common symptom in both expert advice should be sought from an ENT spe-
children and adults. Other symptoms include bad cialist. The choice of antibiotic will depend on
breath, fatigue, and dental pain. Headache is not local patterns of infection and antibiotic resis-
common in children under the age of six. tance. If allergic rhinitis is also present, nasal cor-
Irritability, fatigue, and swelling around the eyes ticosteroids should be used. In terms of poor
together with discoloration below the eyelids and response to therapy, recurrent disease, or chronic
tenderness over the sinuses are indicators [51]. disease, surgical referral should be made.
Pain and systemic symptoms are rare in chronic Symptoms are greatly helped by the use of
sinusitis. Symptoms tend to worsen under physi- steam (e.g., by taking a hot shower), saline for
ologic stimuli, such as temperature changes, nasal lavage (with or without baking soda) [20],
fumes, chemical, dust, and odors [46]. and warm compresses [42]. A vaporizer with warm
Rhinosinusitis is classified as [52]: moist air, used for a brief period of time, is also
helpful. These measures prevent nasal crusting, liq-
• Acute rhinosinusitis: sudden onset, lasting uefy secretions, and act as a mild decongestant.
less than 4 weeks with complete resolution A strong link exists between sinusitis and RS,
• Subacute rhinosinusitis: a continuum of acute on the one hand, and perennial nonallergic rhini-
rhinosinusitis but less than 12 weeks tis on the other [20]. The sequence tends to pro-
• Recurrent acute rhinosinusitis: four or more ceed from profuse rhinorrhea to nasal congestion
episodes of acute, lasting at least 7 days each, to sinusitis. This in turn produces polyps, which
in any 1-year period may lead to bronchial asthma and eventually to
• Chronic rhinosinusitis: signs of symptoms aspirin intolerance. See Fig. 9.1. Asthma, nasal
persist 12 weeks or longer polyps, and aspirin (ASA) intolerance are known
as the asthma triad. Individuals with nasal pol-
Diagnosis of sinusitis involves a detailed yps have a 25–30% chance of developing bron-
physical examination of the nose after a topical chial asthma and vice versa [53]. A study of 33
decongestant. Some items to look for include the adults with both sinus disease and bronchial
following: facial swelling and redness, edema asthma found that 45% had clinical symptoms of
especially around the eyes, cervical adenopathy, sinusitis, 36% were atopic, 90% had nasal pol-
postnasal drainage, or pharyngitis. On looking in yps, and 52% were ASA sensitive [54].
the nose, there may be crusting or pus, polyps, or Rhinitis and RS and asthma interact so often
other defects such as deviated septum. X-rays of that the phrase “united airways disease” is used
the sinuses are used to look for air-fluid levels, [55]. Rhinitis and RS are often present before
opacification, or mucosal thickening. A CT of the asthma is diagnosed, and asthma control may be
sinuses will give a more precise location and help poor until these coexisting conditions are
determine the extent of the disease but is not treated—a combination that the alert asthma edu-
required in the early stages of acute sinusitis. cator will constantly be on the lookout for!
Fig. 9.1 Likely progression of sinus disease

There is also a strong link between sinusitis, They can be seen in the nose as white/yellow
RS, and asthma [20, 45]. Both acute and chronic glistening material. The most useful radiological
sinusitis can provoke asthma [16]. Sinusitis, RS, investigation is a CT scan of the sinuses [58].
and asthma may coexist. More than 50% of those Polyps are almost always multiple and bilat-
with moderate to severe asthma have chronic eral. They are composed of edematous tissue,
RS. A study that compared 46 atopic with 20 with respiratory submucosa covered by respira-
nonatopic children found that 39% of the atopic tory epithelium. They contain many cells, includ-
children had allergic rhinitis (13% of allergic rhi- ing plasma cells, lymphocytes, and eosinophils.
nitis children also had sinusitis), and 61% of the Despite the eosinophils, most polyps are not
atopic children had asthma and rhinitis. After associated with allergy. Common symptoms are
treatment for sinusitis, children with allergic rhi- more likely to occur with large polyps that lead to
nitis and those with sinusitis and asthma had blockage of the sinuses.
decreased bronchial hyperresponsiveness and When polyps occur in asthma, it is most often
reduced symptoms of allergic rhinitis and sinus- in late-onset asthma and in the particular group of
itis [56]. In 80 adults with both asthma and sinus individuals that have the triad of severe nonatopic
disease, it was found that over 90% of them asthma, polyps, and ASA sensitivity [59]. These
reported that sinusitis had preceded the diagnosis should be treated by a specialist and desensitized
of asthma [46]. A study of 200 adults surgically to ASA [60].
treated for chronic sinusitis found that 70% of Polyps are common and a detailed diagnostic
them had immediate skin test reactivity to dust assessment is not usually required. There are spe-
mite allergen [45]. cific situations when further investigations are
When sinus disease improves, respiratory essential. The presence of nasal polyps under the
symptoms decrease. A study where 80 adults age of two requires checking for dermoid or pos-
with both asthma and sinusitis were treated for sible congenital defects. Under the age of 20,
sinusitis reported that 70% of them noted an cystic fibrosis, in which polyps are very common,
improvement in their asthma. Further, 65% were should be excluded. Polyps in any age group may
able to reduce their oral corticosteroids, and one indicate a tumor.
in three no longer required oral corticosteroids to Management of polyps is straightforward but
control their asthma [46]. not always successful. The first line of manage-
In persons with allergic rhinitis, any sign of ment is nasal corticosteroids [61]. As in every
infection should be treated promptly to prevent person on topical corticosteroids, care should be
the development of sinusitis [46]. Sinusitis taken that their use in a number of different areas
may be the underlying cause of the asthma (nose, lungs, skin) may lead to a total dose which
[57]. In particular, sinusitis should be consid- will have systemic effects. Another option is the
ered in those with chronic, difficult to control use of omalizumab in adults 18 years or age and
asthma [47, 53]. Constant vigilance for this older.
disorder is required, and caution is necessary If inhaled corticosteroids do not work, the
as the nasal corticosteroids may, in those individual should be seen by an otolaryngologist
receiving inhaled corticosteroids, increase the with a view to removing the polyps surgically.
risk of side effects. Polyps may recur after surgery.
9.5 Nasal Polyps 9.6 Gastroesophageal Reflux
Nasal polyps are common in adolescents and Gastroesophageal reflux disease (GERD) occurs
adults and affect smell and therefore taste, by when the reflux of gastric contents causes symp-
causing blockage in the nose. They may also lead toms and problems. GERD may affect between
to obstruction of sinus drainage and to sinusitis. 8% and 33% of the population [62]. When gastric
contents pass through the esophagus into the increase while lying down or sleeping. GERD
pharynx, they can be aspirated past the vocal may not always present with obvious symptoms,
cords and down into the trachea. Laryngeal prob- while the symptoms of silent reflux may or may
lems include hoarseness and pulmonary aspira- not include:
tion. The degree of problems depends on the
amount, content, and acidity of the aspirate. The • Cough
severity of this disease is worsened by obesity • Choking
and depends on: • Hoarse quality to the voice
• Recurrent otolaryngologic symptoms
• The degree of loss of pressure of the lower • Respiratory symptoms
esophageal sphincter
• How quickly gastroesophageal clearance In children, the most conspicuous symptoms
takes place are [69]:
• The volume of gastric contents that are
refluxed • Spitting
• Gagging or choking
GERD has also been related to food allergy • Vomiting
[63]. Kotzan and others found that nonsteroidal • Failure to thrive
anti‑inflammatory prescriptions were associated • Anemia
with GERD in females, in tobacco and alcohol
users, and in those who suffered from asthma, GERD is one of those chronic conditions
hiatal hernia, or obesity [64]. GERD has also (including vocal cord dysfunction, rhinitis, and
been linked to obesity, which in turn has been sinusitis) that can masquerade as, or coexist with,
linked to adult-onset asthma [64, 65]. asthma. A number of factors such as increasing
GERD is a common problem. Between 7% age, male gender, chronic sinusitis, and GERD are
and 10% of the US population experience symp- associated with increased severity of asthma [70].
toms on a daily basis, while 15–44% experience Harding found that asthma and GERD may coex-
symptoms at least once a month [65]. Symptoms ist in 77% of individuals with asthma [71]. In help-
(see Table 9.2) include heartburn or indigestion, ing those with asthma, GERD must always be kept
regurgitation, an acid taste in the mouth, frequent in mind. Symptoms attributed to one, such as noc-
belching, epigastric pain or chest pain, dysphagia turnal cough, may be due to the other, or to both.
(difficulty swallowing), and water brash [66–68]. GERD is a potential trigger of asthma [72–75].
This last symptom is described as the sudden fill- It causes respiratory symptoms but does not affect
ing of the mouth with a tasteless, clear liquid. It is pulmonary function [66, 76]. During episodes of
due to the regurgitation of saliva that has accu- GERD, individuals also experienced asthma
mulated in the esophagus and is often preceded symptoms [77]. GERD causes bronchoconstric-
by transient epigastric pain. Symptoms tend to tion in those with moderate to severe asthma.
GERD and both the severity and duration of
bronchoconstriction can be related to the dura-
Table 9.2 Symptoms of GERD tion of reflux [78]. Field found that 28% of indi-
Typical symptoms Atypical symptoms viduals in his study used their asthma reliever
Heartburn/indigestion Cough medication to deal with GERD symptoms and
Regurgitation Choking
also that the severity of asthma symptoms corre-
Frequent belching Hoarseness
Chest pain Respiratory symptoms lated with the severity of GERD [79]. Treatment
Dysphagia of GERD resulted in a majority of them experi-
Water brash encing relief from asthma symptoms and a reduc-
tion in medication requirements, even without clues include choking; pain in the chest, ear, or
any improvement in lung function [74, 76, 80, neck; sore throat; or hoarseness [66, 77].
81]. Harding and others [82] found a strong cor- Tests to confirm/exclude GERD, assess its
relation with respiratory symptoms. In those with severity, and ensure absence of other gastrointes-
asthma and GERD, 100% were short of breath, tinal diseases include barium contrast study,
47% wheezed, 39% coughed, and 57% had chest endoscopy, a treatment trial of proton pump
pain. Harding also found that those who had inhibitor therapy, and a 24-hour ambulatory
GERD symptoms also had more severe asthma. intraesophageal pH monitoring [66, 69, 82, 87].
Field [80] further suggested that reflux causes The latter is considered the best of the current
dyspnea and that individuals with asthma inter- tests to confirm the presence of GER and assess
pret GERD symptoms as discomfort due to its severity. The most cost-effective way of diag-
asthma. He and others [78] found that while 77% nosing asthma that is triggered by GER is a
of those with asthma experience heartburn, 55% 3‑month trial of a proton pump inhibitor followed
had regurgitation and 41% had reflux-associated by esophageal pH testing for nonresponders [81].
respiratory symptoms (RARS). During such a trial, a symptom diary needs to be
The possibility of GERD is another reason to kept and at the end of the trial FEV1 must be mea-
avoid theophyllines. The use of theophylline sured, since symptom improvement may occur
increases GER by 24% and the amount of without any change in the asthma.
reported heartburn and regurgitation by 170% Treatment ranges from the non-medication
[66, 67]. Theophylline increases gastric produc- approach, through appropriate pharmacologic
tion and reduces the pressure of the lower esoph- therapy, to surgery. Both medical and surgical
ageal sphincter (LES), which permits reflux of treatment can lead to improvement in asthma
gastric acid into the esophagus [16, 76]. This control in individuals where the diseases are con-
reduction in tone of the LES is also associated comitant [82, 88–90]. Anti‑reflux therapy in older
with systemic beta-agonists but not associated children [91] can also result in significant reduc-
with inhalation therapy [67]. There is also con- tions in the use of both short and long‑acting
cern about the connection between GERD and bronchodilators and even in the dosage of inhaled
oral corticosteroids. A study [83] of 20 adults corticosteroids.
with stable, moderate persistent asthma and A proper treatment regimen should include
GERD symptoms of less than three times a week multiple components. The first line of medica-
found that 60 mg/day of prednisone for 7 days tions should be over-the-counter (OTC) antacids.
increased esophageal acid contact times without Then, one of the newer medications may be pre-
a corresponding increase in symptoms. scribed for regular preventive use. See Table 9.3.
A standard approach when asthma is difficult Secondly, relief from symptoms of GERD is
to control has already been described. Healthcare often obtained if pharmacologic therapy is com-
professionals should check on adherence, avoid- bined with simple avoidance strategies that
ance of triggers, inhaled corticosteroid usage, include [15, 66, 67, 69, 92, 93]:
and inhaler technique. In many cases, the treat-
ment for asthma has been tried but found to be
Table 9.3 Medications used to treat GERD
ineffective. At this stage, alternate diagnoses
Class Generic name Trade name
must be considered, and GERD is a strong pos-
Antacids Many Many
sibility [15, 16, 77, 84–86]. H2 antagonists Ranitidine Zantac
When asthma therapy appears to be ineffec- Famotidine Pepcid
tive in achieving control, evaluation of GERD Proton pump inhibitors Omeprazole Prilosec
should be considered especially if symptoms are Lansoprazole Prevacid
worse after meals or when lying down. Other Mucosal protector Sucralfate Carafate
• A high-protein, low-fat (45 gm) anti‑reflux 9.7 ocal Cord Dysfunction

V
diet comprised of three meals daily (VCD)
• Avoidance of certain foods such as tomatoes,
citrus juices, chocolate, peppermint, caffeine, Vocal cord dysfunction (VCD) was mentioned in
hot spicy food, and fatty meats Chap. 4 as a possible alternative diagnosis for
• Avoidance of fatty meals, alcohol, and oral asthma. It is also mentioned here because of its
beta‑2 agonists importance in the ongoing management of
• Abstinence of food and beverages between asthma. VCD can coexist with asthma, GERD,
meals and 2–3 hours before bedtime and severe postnasal drainage. Although it is an
• Antacids taken at bedtime upper respiratory (laryngeal) disorder with inspi-
• Elevation of the head of the bed with 6‑ or ratory stridor rather than the lower respiratory
8‑inch blocks (pillows do not suffice and are expiratory wheeze of asthma, it is frequently con-
not recommended) fused with asthma [95]. It should be considered
when there is a poor response to apparently
There is no immediate response to therapy. appropriate treatment for “asthma”, including
Successful therapy for chronic cough due to exercise-induced symptoms [96], despite
GERD may require between 2 and 3 months adherence to the prescribed regimen. VCD is

before any improvement in the cough begins to considered one of the functional disorders of the
show and anywhere from 5 to 6 months for suc- respiratory tract along with hyperventilation syn-
cess [65, 87, 92]. drome, sighing dyspnea, and psychogenic cough
Irwin and others, in studying those with dif- [97]. It should not be confused with structural
ficult to control asthma, found that GERD was disorders of the upper respiratory tract such as
the single most common factor [85]. Of those swelling or narrowing, tumor or polyps, or vocal
treated for GERD, 64% had a favorable response cord paralysis. In these disorders, symptoms are
to therapy, while 24% had “silent” GERD, not likely to be intermittent.
which is asymptomatic of gastroesophageal What is vocal cord dysfunction or VCD? In
reflux. It is interesting to note that Harding, in normal inspiration, the vocal cords open to their
reviewing ten surgical studies of 318 asthmatics widest and then narrow slightly during expira-
with GERD, found that 80% improved and more tion. In VCD, the vocal cords close partially,
than half—many of them on oral obstructing the airway [96–100]. This abnormal
corticosteroids—no longer required any asthma movement can cause recurrent wheezing that is
medication [67]. easily mistaken for asthma. If the vocal cords
While it is known that GERD and asthma close during inspiration, this may be confused
often occur in the same individual, it is not with life‑threatening anaphylaxis.
known if a causal relationship exists. If there is, The literature is confusing partly because of
it is not clear if asthma causes GERD, or vice the different perspectives of various authors. An
versa, or whether both somehow interrelate. early report [99] identified five individuals with
Mechanisms have been postulated that may “asthma” refractory to standard therapy.
explain the possible interaction between GERD However, during exacerbations, flow‑volume
and asthma. They include microaspiration of loops were in keeping with upper airway obstruc-
gastric juices that irritate the pulmonary tree, tion, and laryngoscopy showed the vocal cords
heightened bronchial reactivity due to GERD, tightly together throughout the respiratory cycle.
and a vagally mediated reflex [65, 67, 76, 87]. It was speculated that it was a psychiatric con-
Despite many studies, the precise nature of the version reaction. A single case report [100] of an
relationship between asthma and GERD has still 11-year-old boy with life-threatening episodes
not been clarified [68, 94]. of apparent “asthma” was shown to have vocal
9.7 Vocal Cord Dysfunction (VCD) 303
cord spasm. Following explanation and relax- voice changes, and difficulty in speaking, it is
ation exercises, no further episodes occurred. In clear that some of these symptoms are similar to
yet another report of three cases from a psychia- those of asthma [77, 105, 106]. Common triggers
trist, childhood sexual abuse was identified include respiratory infections, emotional upset,
[101]. While a case‑controlled pediatric series fumes, odors, singing, talking, stress, and tobacco
comparing VCD children with asthma and con- smoke.
trols showed a higher rate of anxiety diagnoses Two studies have examined exercise‑related
in the VCD group, there were no differences in symptoms of VCD. McFadden reported seven
family functioning between the two groups elite athletes who presented with acute dyspnea
[102]. during sporting competitions [96]. They had
Larger studies, even if retrospective and of a challenge tests with cold air or methacholine and
narrowly defined population, have provided some had laryngoscopy. Features distinguishing
more general information. For example, VCD from asthma were:
O’Connell and others [103] studied 164 indi-
viduals who had had fiber optic rhinolaryngos- • Lack of consistency in response to the same
copy. Asthma was the most common presenting stimuli
diagnosis in 75% of them, and 44% had been • Onset of breathing difficulties during exercise
treated with oral corticosteroids for their • Poor response to asthma medication
“asthma.” Forty-five percent of these were found • Extra‑thoracic obstruction on the flow‑volume
to have a psychological trigger. In those cases loop
where VCD masqueraded as stridor, the diagno-
sis had been anaphylaxis. Since they had not Morris [107] evaluated 40 persons with dys-
responded to traditional therapies, the differen- pnea on exercise for VCD; 15% had VCD: of
tial diagnosis of paradoxical vocal cord motion those, 60% had abnormal flow-volume loops
or VCD was finally made. One of the largest after methacholine challenge.
studies, by Newman, was a retrospective review In VCD, examination will be negative. Even
from 1984 to 1991 of 95 individuals diagnosed when asymptomatic, one in four persons with
with VCD, of whom 55 had coexistent asthma VCD will have an abnormal inspiratory section
[98]. Many of them were on prednisone, and in their flow-volume loop. During episodes,
their emergency department use was “enor- whether natural or induced by cold air or metha-
mous”. A more recent study by Yelken found choline, there will be variable abnormalities of
that VCD is significantly higher in those indi- the inspiratory flow-volume loop. Diagnosis is
viduals with asthma than those without asthma, generally confirmed through examination of the
and it may be that asthma is involved in the vocal cords by an experienced otolaryngologist.
paradoxical dysfunction of the larynx [95]. Proof is provided if the larynx is seen during an
The conclusion is that VCD is a common dis- acute attack.
order, particularly prevalent in females between The individual will be helped by a team, usu-
adolescence and 40 years of age, elite athletes, ally including an otolaryngologist and speech
military recruits, and individuals who have had therapist for education with regard to relaxation
high exposure to irritants. They may be well- techniques, panting breathing, slow relaxed expi-
educated, and some are connected with ration techniques, breath holding, and so on. The
health‑related disciplines [98, 104]. prognosis is good with treatment.
VCD can occur with and without asthma and The educator who suspects VCD should
with and without exercise symptoms. As symp- review the person’s history and ask, for example,
toms of VCD include wheezing, cough, dyspnea, if the dyspnea is inspiratory or expiratory and
tachypnea, choking sensation, chest pain, stridor, whether the discomfort is maximal in the neck or
the chest. VCD should be considered when there • Chronic bronchitis and emphysema
is uncontrolled asthma and [97]: • Asthma, chronic bronchitis, and emphysema
• Poor response to rescue or reliever In clinical practice, asthma and COPD may be
medication difficult to distinguish especially in smokers, ex-
• Lack of nocturnal symptoms smokers, and older adults, since these conditions
• Atypical triggers can overlap. Initial items to consider include:
• Sudden occurrence and speedy progression of
symptoms • Age of onset—in asthma, the age of onset is
• Exercise symptoms during (not after) exercise usually childhood though it can occur at any
age. COPD and ACO are generally seen in
The educator should: adults over the age of 40 years.
• Family history—can help determine if the
• Provide an explanation and reassurance, since symptoms are related to asthma.
management of this disorder is generally • Symptoms—in asthma will vary from day to
successful. day or over longer periods while symptoms in
• Ensure that coexistent disorders such as rhini- COPD and ACO are usually chronic and
tis and postnasal drip are treated, for such continuous.
treatment too can improve VCD [108]. • Lung function—between symptoms may be
• Stay in close touch while medication doses are normal in asthma but indicate persistent air-
adjusted for those who have coexisting asthma. flow limitation for COPD and ACO.
• Be aware that some individuals with VCD will • Allergies—are associated with asthma, and
require more extensive counseling than others. exposure to noxious gases such as tobacco and
biomass fuels indicates COPD while ACO is a
combination of both.
9.8 Asthma-COPD Overlap (ACO) • Chest X-rays—while usually normal in
asthma, may change in COPD and ACO and
As previously noted, the old practice of trying to include severe hyperinflation.
separate asthma from COPD has been shown to
be fallacious. The Global Initiative for Asthma An adult aged 40 or more with dyspnea on
(GINA) [16] describes but does not define ACO exertion, a significant smoking history (tobacco
as “characterised by persistent airflow limitation or exposure to toxic gases), and fixed airway
with several features usually associated with obstruction who has asthma symptoms should be
asthma and several features usually associated considered a candidate for ACO [109].
with COPD. ACO is therefore identified by the The requirements for a diagnosis of COPD
features that it shares with asthma and COPD.” and ACO also include spirometry. See Table 9.4.
The prevalence of ACO ranges from 2% to 55% The GINA recommends the following for all
depending on the criteria used. COPD encom- individuals with chronic airflow limitation, that
passes chronic bronchitis, emphysema, and is, COPD and ACO:
asthma subtypes that are linked to chronic airflow
limitation that is not fully reversible. ACO • Treatment of modifiable risk factors (e.g.,
includes respiratory obstruction in those with: smoking cessation)
• Treatment of comorbidities
• Asthma • Physical activity and pulmonary
• Chronic bronchitis rehabilitation
• Emphysema • Vaccinations
• Asthma and chronic bronchitis • Appropriate self-management strategies
• Asthma and emphysema • Regular follow-up
9.9 Obstructive Sleep Apnea 305
Table 9.4 Requirements for a diagnosis of asthma-COPD overlap

Requirements for a diagnosis of ACO
Spirometry Asthma COPD ACO
FEV1/FVC normal Pre/post Yes No No
SABA
Post FEV1/FVC <0.7 Indicates airflow limitation Required Usually present
but may improve on
treatment
FEV1 <80% post SABA Yes. Risk factor for Indicator of severity of airflow limitation and
exacerbations future risk of exacerbations and mortality
Post SABA increase in FEV1 Seen at some times but not Common and likely when FEV1 is low
>12% and 200 ml indicating when well controlled
reversibility
Post SABA increase in FEV1 High probability for asthma Unusual in COPD. Consider Compatible with
>12% and 400 ml showing ACO ACO diagnosis
marked reversibility
Abbreviations: ACO asthma-COPD overlap, FEVi forced expiratory volume in 1 second, FVC forced vital capacity,
SABA short-acting beta-agonist
Adults should be referred to specialists if: ACO is common among adults with chronic
obstructive airflow. The burden it imposes is sig-
• Symptoms persist despite treatment. nificant, and treatment is expensive. Adults with
• They have atypical or additional symptoms. ACO were 134% more likely to have ED visits
• There is uncertainty about the diagnosis. when compared to an asthma group (53%) and a
• There is a need to exclude alternative diagnoses. COPD group (21%). Besides more ED visits,
• Control is difficult due to comorbidities. ACO individuals tend to have more hospitaliza-
• The diagnosis is difficult to make. tions and asthma exacerbations than those with
• There is a need for specialized investigations. asthma alone. They also use the most healthcare
resources when compared against the general,
A risk factor for ACO is the presence of mold asthma, and COPD populations [112, 114, 115].
odors—not at home but in the workplace [110].
Individuals with COPD generally have two or
more exacerbations every year while those with 9.9 Obstructive Sleep Apnea
ACO may have three times as many [111].
Treatment involves the prevention of exposure to As already established, the upper airway is
risk factors, control of symptoms, reduction in important in those with asthma, and the common
exacerbations, and improvement in health-related association of nasal allergies and asthma has
quality of life (HRQoL) [112]. been noted. In asthma, even without upper air-
Individuals with ACO have poor quality of way disease, sleep is often disturbed by cough
life, experience frequent exacerbation, and have a and therefore nighttime symptoms are common
more rapid decline in lung function and high in asthma. But obstructive sleep apnea (OSA)
mortality. They also use a disproportionate may be associated with severe rhinitis. Hence,
amount of healthcare resources. Kauppi and col- whenever nocturnal symptoms are elicited,
leagues [113] studied 1546 adults who had been asthma educators must ask relevant questions
diagnosed with asthma, COPD, or both, evaluat- that will help precisely define the problem.
ing their HRQoL. The ACO group was found to Sleep apnea is defined as pauses of breathing
have the poorest HRQoL. HRQoL was even occurring during sleep and may be central,
lower if the person was female, obese, or disabled obstructive (OSA), or mixed. OSA is the most
and had a long duration of disease and coexisting common form of sleep apnea with periodic upper
cardiovascular disease. airway collapse during sleep and sleep disrup-
tion, leading to immediate daytime symptoms apnea, but 9 (40.9%) had moderate to severe
and long-term complications. For example, there OSA. They point out that such a large proportion
is a higher incidence of motor vehicle crashes in of those with OSA is much beyond expected,
sufferers and common complications are daytime which might be of the order of 5%. They believed
sleepiness, cognitive deterioration, and mental many factors contributed to this association, and
illness (depression) [116]. Medical complica- in some of the adults, they wondered whether this
tions involve mainly the cardiovascular system was a manifestation of a side effect with systemic
with hypertension and stroke, heart arrhythmias corticosteroids. Researchers have found that indi-
and cardiac failure, and sometimes pulmonary viduals with asthma with OSA had more severe
hypertension. OSA is important because of its exacerbations, more frequently than those with-
complications and its impact on the life of those out OSA [119, 120].
affected. In yet another study, 39 individuals, each with
A suspicion of OSA may come from the indi- more than three exacerbations/year were com-
vidual’s description of daytime problems such as pared with 24 who had only one exacerbation/
memory loss, poor judgment, irritability, or year [121]. OSA was found more often in those
depression or morning headaches or a finding of with more exacerbations (OR 3.4). Other impor-
high blood pressure. The older the person, the tant factors in the frequent relapsers were GERD,
more OSA should be suspected. This also applies severe sinus disease, recurrent (respiratory)
for significantly overweight individuals. Real infections, and psychological concerns. These
clues come from the bed partner. The partner will risk factors did not occur singly; half of them had
notice snoring, which is an essential part of sleep three or more cofactors [122]. In a review [123]
apnea but will also notice the characteristic of the relationship between GERD and OSA, the
pauses in breathing, with loud snorting as the authors did not review the relationship between
breathing restarts. Unless questions are directed GERD and asthma but accepted that there was a
specifically to the quality of sleep, OSA will not relationship. Once they reviewed all the evidence,
be detected. they concluded that “GERD and OSA potentially
While the first step to diagnosis is being aware exhibit a two-way, mutually reinforcing
and suspicious of OSA and asking appropriate relationship.”
questions, confirming the diagnosis can be time- Thus, it is very important, in treating individu-
consuming and expensive. Tests that can be car- als with asthma, to consider episodes at night
ried out at home are recommended in some and, perhaps, to seek evidence for both GERD
centers [117]. Definitive diagnosis is done and OSA during sleep. This concept has been
through polysomnography (PSG), which is an taken further. Arter et al. [124] speculate, as have
overnight study, carried out in a laboratory, that others, that hypoxemic episodes generate cyto-
records sleep quality and the degree of abnormal- kines and superoxide radicals exacerbating air-
ity. During PSG, they can also be assessed for way reactivity. This group suggests the acronym
treatment. CORE to emphasize the associations of Cough,
The prevalence of OSA seems to be higher in Obstructive sleep apnea, Rhinosinusitis, and
persons with asthma in general, but is it higher Esophageal reflux.
with deterioration in asthma? Yigla et al. [118] Whether adults or children, detailed question-
investigated the prevalence of OSA in a group of ing must be taken of the quality of sleep and of
individuals and focused over a 1-year period on daytime symptoms that may suggest sleep apnea.
22 who had difficult-to-control asthma. They Individuals with asthma have an increased inci-
recorded details of the asthma, current therapy, dence of sleep disordered breathing, OSA,
past and current pulmonary function tests, arte- GERD, and nocturnal cough. If OSA is likely,
rial blood gases, body mass index, and PSG. OSA they may need formal studies (PSG). Their
was found in 21 (95.5%) of those with difficult- asthma may benefit from specific treatment of
to-control asthma. Twelve of them had mild sleep this nocturnal problem.
9.10 Bronchopulmonary Aspergillosis (ABPA) 307
9.10 Bronchopulmonary noninvasive colonization. Persistent inflamma-

Aspergillosis (ABPA) tion can result in bronchiectasis (abnormal dila-
tion of the bronchi) in those with asthma.
Allergic bronchopulmonary aspergillosis Exposure to the fungus can vary from mild to
(ABPA) is a hypersensitivity reaction in the air- progressive limitation or life-threatening,
ways caused by exposure to an ubiquitous organ- depending on the individual and the degree of
ism, a nonparasitic fungus known as Aspergillus, immunosuppression.
that lives on dead or decaying organic matter. ABPA is a chronic, progressive disease that
While there are over a hundred different species primarily affects individuals with airflow obstruc-
of Aspergillus, only a few are pathogenic to tion, such as asthma and bronchiectasis. ABPA
humans. The Aspergillus antigen is Aspergillus should be suspected in those with difficult or
fumigatus or A. fumigatus. Aspergillus enters the poorly controlled asthma and considered particu-
human body through inhalation—usually through larly in those with corticosteroid dependency
the nose to the lungs and rarely through the and, to a lesser extent, in those who have negative
mouth or skin. Exposure to Aspergillus can result skin tests but frequent exacerbations.
in colonization of the airways followed by dis- ABPA is both underdiagnosed and under-
eases, such as allergic rhinitis, sinusitis, asthma, treated and is most often seen in individuals with
hypersensitivity pneumonitis, invasive aspergil- asthma and cystic fibrosis [127]. ABPA should be
losis, and ABPA. suspected in those who present with wheezing,
Aspergillus is found everywhere in nature—in expectoration of brown mucus plugs, chest pain,
air, soil, sludge, organic debris, waste, mulches, and fever [128]. The symptoms are similar to
compost, rotted plants, freshly mown grass, dust, those for asthma and will include dyspnea, cough,
foods, and spices. It grows outdoors on decaying wheezing, and exercise intolerance. Suspicion
vegetation and can even be found indoors (e.g., in can be verified by radiologic and serologic test-
air-conditioning systems or damp houses). It has ing. A positive sputum culture of A. fumigatus is
also been isolated in medications, paint, refriger- not essential for the diagnosis. The essential ele-
ator walls, and dialysis bags [125]. It is also a ments for diagnosing a person with ABPA include
source of occupational disease. The Aspergillus [128]:
fungus generates so many spores that it is esti-
mated that a human will inhale at least several • Asthma
hundred a day [126]. For most individuals, inha- • Immediate skin reactivity to A. fumigatus
lation of Aspergillus causes no harm. But to those • Serum IgE level > 1000 ng/mL
with previous lung disease (such as asthma) and • Central (proximal) bronchiectasis
those whose immune systems are suppressed or • Elevated IgE and IgG to A. fumigatus
severely compromised, this antigen is a threat. It
is thought that impaired mucus clearance and air- Not all of the above criteria need to be present
way obstruction favor the germination of the to make a diagnosis. ABPA is usually suspected
spores. when there is pulmonary eosinophilia, or mucus
Aspergillus thrives at a temperature of impaction (mucus plugs containing A. fumiga-
37 °C. It is a filamentous fungus—a non- tus), or after skin and serologic testing.
chlorophyllous organism that depends on exter- Repeated exposure and inhalation to A. fumig-
nal nutrients under nearly all possible atus can activate the immune system to initiate
environmental conditions [12]. The small spores, the inflammatory cascade with immediate airway
in the range of 2–3 microns in size, are easily constriction and reduced lung capacity [129].
inhaled deep into the lungs [121]. They can reach The long-term result could be chronic bronchitis,
the terminal airways or may be deposited in the asthma, alveolitis, farmers’ lung, or mushroom
bronchi. Within the lumen of the bronchi, the workers’ lung. It is essential to begin treatment as
spores grow and growth may be limited to a early as possible because delays will result in
irreversible pulmonary damage. Left untreated, and prevention of disease progression to bronchi-
what begins as local inflammation can, due to ectasis and permanent lung damage [128–131].
recurrent exacerbations, cause irreversible bron- The mainstay of treatment for ABPA is oral, not
chiectasis and pulmonary fibrosis. inhaled, corticosteroids that suppress the immune
During acute attacks, there may be loss of system and minimize the secondary inflammatory
lung function due to mucoid impaction of the air- consequences. This reduces bronchoconstriction
ways. In time, central bronchiectasis and pulmo- and pulmonary infiltrates and decreases both IgE
nary fibrosis develop. IgE levels can be used as levels and peripheral eosinophilia. The recom-
markers for exacerbations and to assess the mended dosage is 0.5 mg/kg/d for 2 weeks. Next,
response to therapy. In later stages, CT scans are the oral corticosteroids (OCS) should be given on
helpful to track changes within the lungs. alternate days for 6–8 weeks and then slowly reduced
The disease has been divided into five stages, over 3–6 months. Caution should be observed in
though not all individuals progress through all reducing the OCS, and the person should be closely
five stages [130]: monitored as the dosage is reduced.
Remission is said to be achieved when no oral
• Stage 1 is called the acute stage. It is rarely corticosteroids have been needed for 6 months
diagnosed in the first stage which is marked and without any symptoms. However, during
by asthma, elevated IgE levels, peripheral this stage, the disease progression should be
eosinophilia, pulmonary infiltrates, and both monitored with serial chest radiographs, serum
IgE and IgG antibodies to A. fumigatus. IgE levels, and pulmonary function testing. This
• Stage 2 is the remission stage. is also helpful in identifying potential
• Stage 3 is the exacerbation phase where IgE exacerbations.
levels are double that at baseline. At Stage 4, when corticosteroid therapy can-
• Stage 4 occurs when the person who has been not be discontinued, the lowest dose of OCS
treated with corticosteroids attempts to reduce should be used to minimize side effects and tox-
the corticosteroid therapy but sees a worsen- icity. In addition, adjunct therapies, including
ing of symptoms and the development of pul- antifungal agents, should be considered.
monary infiltrates. They are now Antifungal agents such as itraconazole (200–
corticosteroid-dependent. Serum IgE levels 400 mg/d) and voriconazole can help reduce the
tend to be normal or elevated, while the CT dosage of OCS while improving both exercise
scan will show central bronchiectasis. tolerance and pulmonary function. In those who
Regretfully, it is at this stage that they are usu- are stable, they reduce eosinophilic airway
ally diagnosed with APBA. inflammation, systemic immune activation, and
• Stage 5 is attained by a minority of individu- exacerbations [132]. They should be prescribed
als. This stage is typical of end-stage lung dis- for a duration of 16 weeks. Omalizumab has also
ease with dyspnea, low SpO2, cor pulmonale, been found to be helpful [129]. In the end stage
and clubbing. of the disease, treatment recommendations are
scarce. The prognosis is poor and individuals
The staging system is helpful to gauge a per- often develop recurrent infections.
son’s response to therapy, to assess the progres- Early treatment of ABPA can prevent the pro-
sion of the disease, to identify exacerbations, and gression of the disease into its further stages of
to suggest treatment. Not all follow the five recurrent exacerbations, further bronchiectatic
stages, and predictions based on the above stag- changes, and, finally, respiratory compromise
ing are uncertain for much depends on the indi- and end-stage fibrosis. Individuals should be
vidual and their response to therapy. monitored for loss of lung function to avoid fur-
The four goals of treatment in ABPA include ther deterioration, and as always, the goal of
symptoms control, prevention of exacerbations treatment should be prevention of loss and main-
of ABPA, reduction of pulmonary inflammation, tenance of good respiratory function.
9.11 Depression 309
9.11 Depression than those with either minimal or no depressive

symptoms. Further, unlike adults without asthma,
Chronic illness lends itself to depression. In the in adults with asthma and major depression, there
USA, adults with asthma have more than double was a 4.3% reduction in bronchodilator response
the rates of anxiety and depression compared [142].
with adults without asthma [133]. It is estimated Depression can lead to suicide. A study by
that two out of three individuals with asthma may Clarke and colleagues [143] found that there is a
suffer from depression, and researchers have link between chronic respiratory diseases, depres-
linked depression with increased severity of sion, suicide ideation, and suicide attempts.
asthma [134]. Depression may exacerbate asthma Analysis of data from 5692 adults found that
and asthma in turn can exacerbate depression while 4.2% of adults attempt suicide, the ratio for
[135]. adults with asthma who attempt suicide is 12%.
Oraka and colleagues [133] analyzed data The difference between non-asthma and asthma
from 186,738 adults for the prevalence and risk individuals remained significant even after
factors for serious psychological distress (SPD) adjustment for confounders such as smoking,
and their health-related quality of life (HRQOL). nicotine dependence, age, sex, and race/ethnicity,
Among adults with asthma, the prevalence of depression, panic disorder, and alcohol abuse.
SPD was 7.5%, and no matter their asthma status, The factors that were associated with an increased
there was a negative association between HRQOL likelihood of suicide attempts included:
and SPD. An inverse dose-response relationship
was seen between serious psychological distress • Female sex
and health-related quality of life. Risk factors for • Current smoking
SPD included lower socioeconomic status, smok- • Nicotine dependence
ing, alcohol use, and more comorbid conditions. • Depression
Adults with asthma have a higher prevalence of • Anxiety
frequent mental distress [136]. Research has • Alcohol abuse
clearly linked asthma and mental disorders [137].
Depression, particularly in adolescents with Goodwin [144] found a statistical interaction
asthma, can result in potentially fatal asthma between pulmonary disease, depression, and sui-
[11]. Asthma in adolescence and early adulthood cidal ideation in that the odds increased with
increases the likelihood of major depression, depression:
panic attacks, and any anxiety disorder [138].
Depression in the elderly is linked to lower medi- • Pulmonary disease without depression—OR
cation adherence and poor asthma control and 1.9
quality of life [139]. • Depression without pulmonary disease—OR
Individuals who are obese and depressed have 7.4
poor asthma control. A study of 798 adults found • Pulmonary disease with depression—OR 9.6
an inverse association with BMI and asthma con-
trol after adjusting for age, sex, education, cohab- A study of youth hospitalized for asthma
itation, and ICS use [140]. Children with asthma found higher than expected levels of suicide ide-
who are overweight or obese and have depressive ation [145]. An analysis of 6584 adults whose
symptoms have predicted lower baseline FEV1 data was drawn from the Third National Health
[141]. and Nutrition Examination Survey (NHANES
A study of data from the 2007–2012 National III) found an association between current asthma
Health and Nutrition Examination Survey involv- and suicide ideation (Odds Ratio 1.77) and sui-
ing 20,272 adults between the ages of 20 and cide attempt (OR 3.26), after adjusting for con-
79 years found that individuals with major founders such as mood disorder, poverty,
depression had 3.4 times higher odds of asthma smoking, and demographics [146].
Of all the physical illnesses studied, while sui- sure to known triggers and inadequate adherence
cide was linked primarily to epilepsy, asthma to regular treatment.
ranked second with a relative risk of 1.8 after epi- There is a continuum of acute asthma:
lepsy at 2.9 (followed by psoriasis, diabetes, and
eczema). Psychiatric illness is closely linked to • Wheeze might present for a few minutes after
self-harm and suicide [147]. exercise, followed by spontaneous recovery.
When it came to asthma management, anxi- • Deterioration might occur for several days
ety/depression leads to decreased adherence to after a viral head cold and eventually benefit
medication, monitoring, and smoking cessation. from treatment at home.
The results of anxiety/depression were reduced • There may be deterioration severe enough to
self-care and functioning with increased symp- require aggressive treatment in the ED.
toms burden, healthcare utilization, and medical • Hospitalization may be needed.
costs, all of which have long-term implications • Assisted ventilation in an intensive care unit
[148]. (ICU) may be required.
Hence, any treatment modality for asthma, in
order to minimize the possibility of suicide in Those individuals with the most severe epi-
those with asthma, must incorporate sodes, such as life-threatening asthma in the ICU,
were previously described by the term “status
• Asthma treatment asthmaticus. “While this phrase is still used to
• Smoking cessation indicate severe acute or life-threatening asthma,
• Alcohol surcease it does not convey the full range of severity.
• Behavior modification
• Treatment for depressive disorders
Points to Ponder
It is clear that there is a significant association Respiratory induced changes in asthma
between asthma, depression/anxiety, and suicide.
Hence, educators and healthcare professionals • Interference with speech
should work with individuals to identify associa- • Increase in respiratory rate
tions between depression and asthma in order to • Intercostals indrawing
increase control and reduce the severity of • Wheeze on auscultation
asthma. Those with asthma must be constantly • Changes in breath sounds
assessed not only for physical health but also for • Increase in heart rate
psychological morbidity. • Use of accessory muscles of respiration
• Pulsus paradoxus
9.12 A
cute, Severe Acute,
and Life-Threatening Despite the existence of a continuum of sever-
Asthma ity, individuals do not generally go through a
complete sequence of events. They have particu-
Deterioration of asthma from time to time is a lar patterns, and in some cases, the deterioration
reality, no matter how well-controlled the disease progresses from onset to severe very quickly.
or how much attention is paid to avoiding envi- Thus, it is important to know their previous
ronmental triggers. Sometimes this deterioration response to help predict their course during new
is unexpected and sudden. More often, warning episodes of deterioration. Action plans, described
signs are not identified by the individual or in Chap. 10, can help them identify when they
healthcare provider or are compounded by expo- need to seek help from a clinic or hospital.
However, asthma plans will only help if the Episodes are identified by increased symp-
person: toms, such as wheeze or cough, particularly when
they occur at night. One of the most important
• Understands the plan indicators of deterioration is increased broncho-
• Has the action plan readily at hand when dete- dilator use.
rioration occurs Increased use of an inhaled bronchodilator is
• Is prepared to follow the directions in the plan an important warning sign. It is a sign that calls
for urgent self-assessment followed by appropri-
Some individuals will have normal or near‑nor- ate changes in asthma care. Further action might
mal lung function and will have smooth muscle include stopping activity, such as exercise, or tak-
contraction during exercise. More commonly, with ing environmental precautions (such as removing
acute deterioration, there will already be some pre- themselves from a harmful environment). An
existing abnormality of lung function, due to mild increase in ICS is no longer routinely advised. If
inflammation, an increase in secretion, or perhaps advised to use intermittent ICS, as indicated in
airway remodeling. With acute deterioration, these the following paragraph, now is the time to act.
changes are exacerbated, and secretions start to Systemic corticosteroids might be needed but
block the airway. The combination of inflamma- only with professional direction. When to go to
tory edema, smooth muscle contraction, and air- the hospital or call for an ambulance must be well
way secretions leads to closure of a number of understood.
medium to small airways. The difficulty in breath- One recent change in the Updates to the
ing occurs in both expiration and inspiration but is Asthma Management Guidelines [150] is that in
more marked in expiration. As the attack pro- some situations, ICS are not used regularly but
gresses, the amount of gas trapped in the lung only with exacerbations. The specifics are:
increases, together with an increase in the antero-
posterior diameter of the chest. There is marked • Children aged 1–4 years, recurrent wheezing
ventilation/perfusion inequality—that is, perfu- triggered by respiratory tract infection (RTI)
sion of under-ventilated areas of the lung leads to and no wheezing between infections
the development of hypoxemia. With more severe –– Short course of daily ICS at onset of infec-
and prolonged episodes of deterioration, function + as needed SABA
tional loss of many airways can also occur [149]. • Twelve years and over, mild persistent asthma
The general approach to acute asthma is to: –– As needed ICS and SABA as choice
(Also allowed low-dose regular ICS + as
• Identify deterioration. needed SABA)
• Assess severity. • Four years +, moderate to severe persistent
• Take action as soon as possible. asthma
–– ICS-formoterol in a single inhaler as both
The aims of treatment are to achieve recovery daily controller and reliever therapy
as rapidly as possible; break the vicious circle of (Also allowed higher dose ICS + SABA as
downward deterioration and prevent future epi- needed, or ICS-LABA + SABA as needed)
sodes of acute asthma.
The mainstays of treatment are a beta‑2 ago- There has also been a marked change in the
nist delivered by inhalation, systemic corticoste- guidelines recommendations on how to handle an
roids, and oxygen. All three are not always asthma attack. Since the danger posed by
required and because the route, delivery, and increased inflammation is clear, speedy reduction
detailed dose will vary from person to person; a of inflammation is the goal. The emphasis now is
detailed assessment is important. to regain control of the asthma as quickly as
possible with the use of oral corticosteroids noted whether the person can speak in sentences,
(OCS). Frequent exacerbations are known to phrases, or only syllables. Other important find-
impair lung function and accelerate the decline in ings include an increase in respiratory rate, an
lung function [151–154]. increase in tracheal tug or intercostal indrawing,
Exacerbations/attacks are defined as a wors- use of accessory muscles of respiration, or evi-
ening of asthma of sufficient severity to require dence of wheeze on auscultation. Findings such
intervention of a medical professional or self- as persistent crackles in one area of the lung
administration of oral corticosteroids. The fre- should be noted, since they may indicate alter-
quency of deterioration may be an indication of nate pathology such as pneumonia.
greater severity or poor compliance with therapy. Marked asymmetry in the intensity of breath
Comorbidities may play a significant role, par- sounds may indicate a complication of the severe
ticularly psychosocial dysfunction and severe attack, such as pneumothorax, atelectasis, pneu-
chronic sinusitis. monia, or inhaled foreign body. Inspection may
While there are many causes for attacks, the also show an increase in anteroposterior diame-
major cause tends to be viral, particularly rhino- ter. The major cardiovascular effect is an increase
virus infection [155]. About 80% of all exacerba- in heart rate. Another well‑recognized cardiovas-
tions are triggered by viral infections with cular finding is pulsus paradoxus. In normal
two-thirds due to the rhinovirus. Bacterial infec- healthy individuals, systolic blood pressure drops
tions, increased exposure to fungal spores, by about 5 mm of mercury during inspiration. In
allergy, extreme weather conditions, psychologi- pulsus paradoxus, this is exaggerated, with sys-
cal stress, and exposure to high levels of air pol- tolic blood pressure falling by 10 mm of mercury
lution, including ozone, nitrogen dioxide, and or more during inspiration, together with an obvi-
living close to roads, are all contributors to exac- ous decrease in the size of the pulse. This is an
erbations [15, 153, 156–158]. It is rarely a single important sign of severe airflow limitation.
trigger that results in an exacerbation but rather The marked hyperinflation of lung in acute
the combined effects of many triggers or repeated asthma leads to major changes in pulmonary
exposures to a few triggers. Some triggers, such pressure, which limits return of blood to the heart
as air pollution, work synergistically with viral during inspiration, and subsequently affects car-
infections and allergic sensitization to provoke an diac emptying. Pulsus paradoxus requires blood
exacerbation. pressure to be measured during both inspiration
and expiration. Although it is potentially useful
as a sign of severity, it may be absent even in
9.12.1 Classification of Severity severe asthma. Moreover, many healthcare pro-
of Acute Asthma fessionals may not perform this measurement
because they think it is not easy to do.
Severity requires: The importance of accurate assessment of the
person with asthma during attack is emphasized
• Assessment of the respiratory system from the realization that some of them will die.
• Assessment of the cardiovascular system Death of course is rare, but not unknown, and
• Objective measurements, including peak flow when the circumstances of death are examined,
and oxygen saturation almost always errors are found. The errors may
• Assessment of blood gases (note that this be on the part of the person with asthma them-
measurement becomes more important the selves, in not maintaining regular anti-asthma
longer the episode lasts) therapy or not escalating therapy at the early
stages of deterioration. The errors may be on the
Respiratory changes can be noted as the clini- part of healthcare professionals in not recogniz-
cian listens to the individual. Episodes of acute ing early enough the severity of the attack. While
asthma interfere with speech, and it should be there may be errors in recognition of deteriora-
Fig. 9.2 Death not due to asthma

Fig. 9.3 Death from asthma
tion, or management of deterioration, almost

always there is a long history of poorly controlled
asthma before the fatal event. When individuals
die due to severe asthma, the lungs show evi-
dence of chronic illness. The illustrations that
follow (Figs. 9.2, 9.3, and 9.4) are casts of the
lung prepared after postmortem examination.
They were obtained as part of a prospective study
of asthma mortality [159, 160]. In this study, all
asthma deaths in three Canadian provinces were
reported to the study investigators. The next of
kin was asked for permission to remove and
study the lungs. The casts were prepared using a
novel procedure described by Perry et al. [159].
In summary, a silicon component was inserted
into the lungs under negative pressure. The casts Fig. 9.4 Changes in the lungs due to asthma
shown are representative of three groups of indi-
viduals studied.
Figure 9.2 was obtained from an individual airway constriction means that many of the seg-
who had a history of asthma but in whom the ments are truncated.
cause of death was unrelated to the asthma. The Figure 9.4 is from an individual who did not
branching pattern is normal, and there was filling die because of asthma but did have a history of
of the airway with the compound to the level of asthma. This cast does not show the extreme
the respiratory bronchioles. changes of Fig. 9.3 but does show some of the
Figure 9.3 is from someone whose cause of changes of faithful asthma, with some changes
death was clearly asthma. There are irregular seg- due to mucous plugs and some airway
ments, tapering, and areas of constriction. The truncation.
Examination of these casts will help to under- such patients require oxygen therapy.
stand the pathophysiological changes described Measurement of blood gases including pH and
earlier in this section and the possible complica- PaCO2 (partial pressure of carbon dioxide) is
tions of severe acute asthma. They also point the essential for those individuals with severe
way to the need for objective measures wherever episodes.
possible early in the period of deterioration. In more severe episodes, or when there are
Measurement of peak expiratory flow, particu- atypical features such as asymmetry of clinical
larly if the previous best is known, can guide findings of chest sounds, a chest X‑ray is required.
therapy at home, in the educator’s office, at the The X‑ray should be scrutinized for areas of
clinic, or in the hospital. The educator should mucus plugging involving major airways, areas
remember, however, that individuals in an acute of pneumonia, or evidence of a pneumothorax. A
exacerbation may not be able to do a peak flow chest X‑ray should not be requested in other less
maneuver. When a reading is obtained, it is com- severe attacks, because the findings can be mis-
pared against their normal “best” reading. Below leading. The usual findings are minor changes
normal readings (50–80% of normal best, or less such as patchy infiltrates representing areas of
than 50%) indicate a severe, or impending severe, atelectasis.
attack. If facilities are available in a clinic or hos- Table 9.5 shows an overall classification of
pital, FEV1 may be done with some help. For severity during an exacerbation, based on the
more severe attacks pulse oximetry should be NHLBI Expert Panel Report 3 Guidelines [15].
performed although normal oxygen saturation Most individuals with mild asthma can be man-
does not indicate the episode is mild. Deterioration aged at home easily, but when seen by the educa-
in oxygen saturation is a very serious sign, and tor, a number of simple measurements are
Table 9.5 Classification of severity and treatment of an asthma exacerbation

Signs and Severity
symptoms Mild Moderate Severe Imminent respiratory arrest
Dyspnea With activity Limits activity At rest Too dyspneic to speak,
Speech Sentences Phrases Words perspiring
Conscious level Agitated Agitated Agitated Confused and drowsy
Respiratory rate >30a
(RR)
Accessory No Yes, some Usually Paradoxical
muscles thoracoabdominal movement
Wheeze End expiration Expiration Loud inspiration and No (silent chest)
expiration
Heart rate (HR) <a 100–120a >120 Bradycardia
Pulsus Paradoxus <10 mm Hg 10–25 mm Hg >25 mm Hg May be absent
PEF as % of ≥70% 40–69% <40% <25%
personal best
SpO2% Normal—not >90 <90 Should be receiving O2
usually measured
PaCO2 Normal—not Normal—not >42 May be high
usually measured usually measured
Treatment At home Office/ED ED/hospital Hospital/ICU
SABA + OCS? SABA + OCS SABA + OCS + IV corticosteroids + adjunct
adjunct therapies therapies
a
Children HR RR
3–12 months <160 <50
1–2 years 120 <40
2–8 years 110 <30
a = refer to attched table for values for children
important. The scheme of management shown tact their physicians for instructions, and oral
has been modified from other sources [9, 161]. corticosteroids may be required.
When dyspnea limits activity and peak flows
9.12.1.1 Assessing an Attack or FEV1 falls between 40% and 69%, then the
The EPR3 Guidelines [15] use two elements to exacerbation is classified as moderate. Other
assess severity: dyspnea, and peak flows or FEV1. signs include loud wheeze on exhalation, the use
Normally, FEV1 should be above 80% of pre- of accessory muscles with suprasternal retrac-
dicted or personal best. Every individual should tion, rapid breathing, and increased pulse rate.
have an asthma action plan (AAP) that would rec- They are usually agitated and speak not in sen-
ommend that a short-acting beta-agonist (SABA) tences but in phrases. They prefer sitting to lying
be taken at the first sign of symptoms. As previous down. Pulsus paradoxus can be present with
mentioned, the action plan may include starting readings in the 10–25 mm Hg range.
an ICS. While no single symptom is predicative The initial treatment is with 2–6 puffs of
of an attack, symptom scores, increased beta- SABA by MDI or two nebulizer treatments
agonist use, daytime cough and wheeze, and 20 min apart. In a moderate exacerbation, they
nighttime medication use are heralds for an exac- get some relief. Unlike the mild exacerbation,
erbation [158]. Deterioration may be slow or peak flows persist between 50% and 79%. They
rapid, depending on the cause and intensity of should follow the AAP and take the SABA every
allergen exposure. Exacerbations, commonly 20 min and OCS as prescribed. They should con-
called attacks by those with asthma, can be classi- tact their physicians urgently. They may require
fied as mild, moderate, or severe with the final further treatment either in the physician’s office
category including the life-threatening exacerba- or in the ED of the nearest hospital. See Table 9.6.
tion. The Lancet Commission commented that In severe attacks, there is dyspnea at rest.
“exacerbations” and “flare-ups” are seen as trivi- Individuals are understandably agitated, speak in
alizing these episodes, and recommended use of words and not in phrases, and prefer to sit
the term “attacks” [162]. It is likely that guideline upright. The respiratory rate is above 30/min.
authors will change their language and start to Retraction of the accessory muscles is obvious.
talk about attacks. Meantime, all three terms are Wheeze occurs both on inhalation and exhala-
used virtually interchangeably in this book. tion. Pulse rate is rapid—over 120 bpm and pul-
A peak flow or FEV1 that is below 80% but sus paradoxus can be noted both in children
above 70% is considered mild. Individuals (20–40 mm Hg) and in adults (>25 mm Hg).
may report being short of breath only with Peak flows are less than 40%, with signs of cya-
activity. At the first sign, they may take 2–6 nosis present. Oxygen saturation will fall below
puffs of SABA by MDI. If the symptoms are 90%.
relieved, they may continue to take the SABA The initial treatment is similar for every attack
every 3–4 hours until they move back into the and starts with 2–6 puffs from an MDI 20 min
green zone. Peak flows should return to above apart. Two nebulizer treatments are an acceptable
80% of predicted or personal best with the alternative. In a severe attack, even a SABA will
SABA. They are required to monitor their not give relief. Peak flows will remain at <50%.
peak flows and symptoms. A further sign of a The SABA should be given immediately, since it
mild attack is that they will have no difficulty is vitally important to keep the airways open, and
lying down. they should take OCS as prescribed and go imme-
If within 24 hours symptoms abate and peak diately to the ED of the nearest hospital. Severe
flows or FEV1 returns to normal, then no further attacks should be treated in ED, and admission to
action is required. However, if after 24 hours they hospital may be required for ongoing monitoring
still require a SABA every 4 hours and there is no and treatment, since the possibility of respiratory
indication of improvement, then they must con- failure exists.
Table 9.6 Treating an asthma exacerbation
Step 1 Give SABA 2–6 puffs by MDI, perhaps with ICS as above
Mild – Moderate– Severe –ED and
Step 2 Assess severity treat at home office/ED Hospital
Symptoms Relieved Some relief No relief

Step 3
Check PEFR% >80% 50–79% <50%
response SABA every 2–3 SABA every 20
hours for 24–48 SABA immediately and
and treat Treatment minutes and OCS as OCS as prescribed
hours
prescribed
Contact
Step 4 physician For instruction Urgently Go to ED
SABA short-acting beta-agonist, OCS oral corticosteroids, ED emergency department
9.12.1.2 The Life-Threatening Attack ued well-being and to minimize the damage done
A critical subset of the severe attack is the life- by attacks, both in the short and long term.
threatening one. The initial approach is similar Those who are at high risk for severe or life-
and SABA should continue to be given as well as threatening attacks generally fall into three
OCS that has been prescribed while the person is groups [163]:
taken to hospital. These individuals:
1. Young or middle-aged with low BMI who are
• Do not wheeze depressive, tend to smoke, are hypersensitive
• Are drowsy and confused to environmental triggers especially pets, and
• Will have paradoxical thoracoabdominal who stopped their asthma controller
movement medications
• Will have bradycardia 2. Middle-aged or older with good adherence but
• Will not have pulsus paradoxus due to respira- low perception of dyspnea
tory muscle fatigue 3. Those with daily symptoms, smokers, and

• Will have peak flows <25% if measurable who had slow steady worsening of symptoms
in the preceding 10 days
There is no time to waste in the life-threatening
attack. Even while giving the SABA, an Another study of inner-city children found
ambulance should be called, and the person taken that African American, male children had a high
to the nearest hospital. mortality risk factors that included ICU admis-
Studies have clearly shown that a major risk sions, extreme poverty, atopy, and overuse of alb-
factor for death from asthma is a recent visit to uterol [164].
ED and/or admission to hospital. Most children The medications required in asthma, as shown
who require hospitalization can be identified by a in Table 9.7, are taken from the guidelines [15].
repeat assessment 1 hour after treatment. Regular Depending on the severity, asthma may be man-
assessment is the key to monitoring attacks and aged in the home, the office, or in the hospital.
deciding whether or not the individual requires
hospitalization. Each person has a unique pattern
of asthma and hence needs an individualized AAP 9.12.2 Treating Asthma in the Home
that tells them what to do, when to do it, how
often to do it, as well as when to get professional When treating acute asthma in the home, indi-
medical help. An AAP is critical to their contin- viduals should be instructed to check their peak
Table 9.7 Dosages of medications for asthma exacerbations

Medications Child dose Adult dose
Inhaled short-acting beta-agonist
Albuterol nebulizer 0.15 mg/kg with a minimum 2.5 mg dose, every 2.4–5 mg every 20 min for 3 doses. Then
solution (5 mg/ml) 20 min for 3 doses. Then 0.15–0.3 mg/kg up to 2.5–10 mg every 1–4 hours as needed, or
10 mg every 1–4 hours as needed or 0.5 mg/ 10–15 mg/h continuously
kg/h for continuous nebulization
MDI (90 mcg/puff) 48 puffs with spacer/holding chamber every 48 puffs every 20 min for up to 4 hours,
20 min for 3 doses. Repeat every 1–4 hours then every 1–4 hours as needed
Pirbuterol See albuterol dosages See albuterol dosages
MDI (200 mcg/puff)
Systemic (injected beta-2 agonist)
Epinephrine (1 mg/ml) 0.01 mg/kg up to 0.3–0.5 mg every 20 min for 0.3–0.5 mg every 20 min for 3 doses
3 doses
Terbutaline (1 mg/ml) 0.01 mg/kg every 20 min for 3 doses then every 0.25 mg every 20 min for 3 doses
2–6 hours as needed
Anticholinergics
Ipratropium bromide 0.25 mg every 20 min for 3 doses, then every 0.5 mg every 30 min for 3 doses then
Nebulizer solution 2–4 hours every 2–4 hours as needed
(25 mg/ml)
MDI (18mcg/puff) 4–8 puffs as needed 4–8 puffs as needed
Corticosteroids
Prednisone 1 mg/kg every 6 hours for 2 days. Then 10–180 mg/day in 3 or 4 divided doses
Prednisolone 1–2 mg/kg/day to a maximum of 60 mg/day in for 48 hours. Then 60–80 mg/day until
Methylprednisolone 2 divided doses until peak flows achieve 70% peak flows achieve 70% of personal or
of personal or predicted best reading predicted best reading
flow. If it is less than 50% of their best, they must sional. If peak flow remains less than 50%, it is
act quickly by taking an effective dose of a likely that there is other evidence of severity such
short‑acting beta‑2 agonist. If they do not rapidly as interference with speech, marked tachycardia,
respond to the medication, they must immedi- and use of accessory muscles. These individuals
ately contact their healthcare provider. An effec- should take oral corticosteroids but should also
tive dose would be 2–4 puffs by metered dose be taken immediately to a hospital.
inhaler, repeated in 20 min. In the unusual situa-
tion where a nebulizer is preferred, one treatment
should be given. Where appropriate, ICS should 9.12.3 Treating Asthma in the Office
also be started, and those on maintenance ICS-
formoterol should take an extra dose. Educators can treat attacks of acute asthma at the
If peak flow rises above 80%, then aggressive office. The extent of the treatment offered, and
use of the inhaled beta‑2 agonist—perhaps one the severity that can safely be treated in the office,
dose every 3–4 hours—may continue for will depend on the experience and profession of
1–2 days. They should inform their healthcare the educator, the support facilities in the office,
provider about the episode, preferably within and the standby arrangements with local emer-
24 hours. gency departments. If the educator is to under-
If, after the initial aggressive treatment, the take treatment of severe asthma, pulse oximetry
peak flow stays between 50% and 80% of previ- should be available, peak flow should be fol-
ous best, then oral corticosteroids should be lowed, and the educator should be skilled in
started, with adults taking 50 mg immediately physical assessment.
and continuing with this dosage for 7 days. The Individuals with peak flows less than 50%
clinician responsible should be informed, and the should be given a high dose of a short-acting
individual may need assessment by a profes- beta‑2 agonist with a metered dose inhaler (pre-
ferred) or nebulizer. Where appropriate, ICS chest compressions (external cardiac massage),
should also be started and those on maintenance which keep oxygenated blood circulating to vital
ICS-formoterol should take an extra dose. While organs such as the brain and heart.
the dose of SABA can be repeated, they should Permanent brain damage or death can occur
be sent to hospital if the response is not rapid. within minutes if blood flow ceases. Although its
For others, when the initial peak flow is greater success rate is low, CPR can help keep a person
than 50%, short-acting beta‑2 agonist can be alive until more advanced procedures, such as defi-
given by metered dose inhaler (2–4 puffs) three brillation, can be started to treat the cardiac arrest.
times in the first hour. Where appropriate, ICS Should the asthma educator be prepared to deal
should also be started, and those on maintenance with such life-threatening crises in the office? The
ICS-formoterol should take an extra dose. If the answer depends on the type of person seen, the
response is not immediate, oral corticosteroids location of the office, and the willingness to admin-
should be started. They should be assessed 1 hour ister treatment—in the latter case, staff training and
later and plans made for the next several days. If availability of full resuscitation facilities are essen-
rapid improvement does not occur, they should tial. In the office, abrupt cessation of heartbeat or
be transferred to hospital. breathing may occur because of other conditions,
If the peak flow reading is between 50% and such as heart disease, as a complication of a treat-
80%, they should be observed directly until there ment, especially immunotherapy, or because of
is improvement beyond 80%, at which point they anaphylaxis. Signs of cardiac arrest include:
can go home. If there is no sustained improve-
ment, they should be sent to hospital. • Dilated, unreactive pupils
Individuals with brittle asthma (see Chap. 4) • Bluish lips
require special care. Arrangements must be made • Pale skin
for their assessment in a comprehensive care • Respiratory arrest
facility, and their fragile status should be identi- • Lack of pulse
fied in advance.
Regardless of whether the person goes home, Once this crisis occurs and is recognized, life-
or is sent to hospital, arrangements must be made saving CPR must be started immediately and
for review in the convalescent phase of the epi- continued until an effective heartbeat and breath-
sode. This is important, as it helps to identify ing can be restored.
triggers for that particular episode and to review Different techniques and ratios of breaths to
both the action plan and the self-management number of compressions are used for infants, for
practices of the individual, all of which may head children, and for adults. The American Heart
off major deterioration. Association offers complete details on techniques
Detailed management of individuals with acute to be used for different age groups and training
severe asthma in the emergency department will (see www.heart.org). Manuals on advanced car-
involve approaches similar to those used by the edu- diac life support (ACLS) may also be ordered.
cator but with the obvious advantage that major
medical facilities are available if they should deterio-
rate. Details of ED care, in‑patient hospital care, or 9.13 Anaphylaxis: Type 1 Allergy
intensive care unit care will not be dealt with here.
Anaphylaxis is also discussed in Chap. 2.
9.12.4 Cardiopulmonary
Resuscitation (CPR) 9.13.1 Definition
CPR, which is used when the heart and/or breath- Anaphylaxis is a severe life‑threatening, general-
ing stops, is a combination of rescue breathing, ized reaction. The word, taken from the Greek,
which provides oxygen to the victim’s lungs, and literally means “without protection.” Hypotension
and shock are the dominant features, and anaphy- These types of reactions may also be idio-
laxis which is the most extreme allergic reaction pathic [165].
can result in death. Food anaphylaxis is of most concern, and
Allergic reactions vary in intensity depending many foods have been associated with anaphy-
on the individual’s predisposition and the quan- laxis. These include milk, eggs, tree nuts, legumes
tity of allergen exposure. The strength of the (particularly peanuts), shellfish, fish, wheat, corn,
reaction will depend to some extent on the beets, berries, seeds, citrus fruits, bananas, grains,
amount of the allergen ingested, inhaled, or con- safflower, soy, and chamomile tea. A recent cause
tacted by the particular individual. The reaction of anaphylaxis is the increased use of pinon or
can occur either within seconds of exposure or pine nuts [166].
some hours later and if untreated will result in In children, the leading cause of anaphylaxis
death. Over 70% of fatal reactions involve respi- is peanuts, followed by milk, eggs, soy, wheat,
ratory complications, while 24% involve cardiac fish, and seeds. Analysis of a 20-year period of
dysfunction. hospital admissions for food-induced anaphy-
laxis in the UK found that anaphylaxis caused
by food has more than tripled, with an annual
Points to Ponder increase of 5.7%. In that same period, 46% of
A severe allergic reaction that involves two all anaphylactic fatalities were triggered by
or more body systems is regarded as peanut or nuts. The single most common cause
anaphylactic. of fatal anaphylaxis among school-aged chil-
dren under the age of 15 years was cow’s milk
[167].
Generally, anaphylaxis occurs only when Preservatives, such as sulfites, metabisulfites,
prior exposure has resulted in allergic sensitiza- and benzoate, as well as colorings, are also
tion (see Chap. 2) and, in some cases, can occur known to cause anaphylaxis. Despite this, food
where there is exquisite sensitivity to minute anaphylaxis has more fatalities in the 20- and
quantities. However, it can also occur without 30-year-old individuals than in other age groups
prior exposure. This latter type of reaction, when [168].
the reaction is clinically similar to anaphylaxis Older age and African American race are asso-
but produced by a different and less understood ciated with anaphylaxis related to food, medica-
nonallergic pathway, is referred to as anaphylac- tion, and allergens [169].
toid [165]. Exercise alone may also lead to anaphylaxis;
As a general rule, any severe allergic reaction this may also occur as part of the oral allergy syn-
that involves two or more body systems is drome. In the latter case, exercise anaphylaxis
regarded as anaphylactic. occurs on some occasions only, and a careful his-
tory will disclose that it follows consumption of
specific foods [170] such as celery, nuts, peaches,
9.13.2 Causes wheat [171], and seafood (particularly shrimp,
oysters, and squid). If ingestion of these foods is
Anaphylactic reactions may or may not be IgE not followed by vigorous physical exercise, there
mediated and can be caused by: is often no subsequent allergic reaction.
Latex allergy is another cause of anaphylaxis.
• Foods It is increasing in incidence, and the educator
• Exercise should routinely ask individuals about their use
• Latex of latex‑based products. This allergy is seen in
• Medications healthcare workers and those with chronic dis-
• Insect stings and venoms eases who use latex gloves and appliances fre-
• Immunotherapy quently [172] (see Chap. 5).
Drug‑induced anaphylaxis [173] can be tamine‑releasing agents. Radiocontrast media is

induced by: significantly associated with fatal drug anaphy-
laxis [165, 169].
• Proteins, such as enzymes, foreign serum, While a person can become anaphylactic to
allergen extracts, and vaccines certain proteins, the reverse is also possible—for
• Nonproteins, such as local anesthetics, sulfon- example, over 90% of infants anaphylactic to
amides, penicillin, and other antibiotics milk will no longer be anaphylactic by the time
they are 8 or 9 years old.
Drug‑induced anaphylaxis is diagnosed by Immunotherapy is a common cause of ana-
history, and the use of the offending medication phylaxis. Idiopathic anaphylaxis is the term used
should be stopped. When examining children, the to describe reactions for which there is no obvi-
educator should be careful to distinguish an aller- ous explanation.
gic reaction to a medication from the rash that
occurs with many viral illnesses and which may
occur after an antibiotic has been given but is not Case Study
due to the antibiotic itself. Cardiovascular dis-
ease and older age are risk factors for anaphylac- Lianne Dunn is 18 years old and has had
tic reactions to drugs [168]. asthma and allergies for as long as she can
Aspirin-induced anaphylaxis is not IgE- remember. She has come to see you since
mediated. Prostaglandin production is blocked she has had to use her epinephrine autoin-
and leukotriene production increases as a result. jector twice in the last 2 months. At both
All NSAIDs may induce anaphylaxis and are, in times, she was at an event where she was
fact, the most common cause of medica- surrounded by tobacco smoke. She felt she
tion‑induced anaphylaxis [174]. The potential for was having an anaphylactic reaction for she
anaphylaxis exists even with acetaminophen, was very short of breath and her throat
although reactions with this medication are very “closed-up.” So, she used her autoinjector.
rare. Antibiotics may also be potential inducers She then went home. However, a few hours
of anaphylaxis, while other causes of anaphylaxis after she got home, she felt extremely tired
may be the preservatives (such as benzoate) and and depressed. This lasted for 2 days. What
coloring agents (tartrazine) in medications. other information would you need in order
Insect sting allergy—to the venom of bees, to help her?
hornets, wasps and fire ants—requires specific Enquire as to other symptoms that
questions, as a history may not be volunteered. occurred during the anaphylactic episode.
Risk factors for fatal venom anaphylaxis include Was shortness of breath her only symptom?
male gender, middle age, white race, and cardio- What other symptoms did she have? Why
vascular disease [168]. A full allergy evaluation did she think the reaction was anaphylac-
should be performed after a severe reaction to an tic? If she thought it was anaphylactic, why
insect sting. Immunotherapy may be warranted didn’t she go to the hospital? Does she
and has proved to be 98% effective [170] in pre- understand what an anaphylactic reaction
venting further anaphylactic reactions. is? (It generally involves two or more body
Iatrogenic reactions include reaction to medi- systems.) She should be checked for
cations and to dyes used in X‑rays and materials VCD. The depression and tiredness are
for allergy testing. These include opiates (mor- likely due to post-adrenaline fatigue, the
phine, Demerol, codeine), radiocontrast media, result of taking the epinephrine
dextran, mannitol, curare, muscle-relaxing agents autoinjector.
given at general anesthesia, and other direct his-
9.13.3 Risk Factors for Anaphylaxis tivitis, wheezing, dyspnea, bronchospasm,

stridor, chest pain, dry staccato cough, and
The risk factors for anaphylaxis include [165, difficulty in talking
170, 175]: • Gastrointestinal: abdominal pain, nausea,
vomiting, diarrhea, incontinence (both urine
• Accidental ingestion and feces), cramping, dysphagia, and metallic
• Asthma taste in mouth
• Nonrecognition and denial of early symptoms • Cardiovascular: hypotension, tachycardia,
• Reliance on antihistamines heart attacks, constitutional cold, clammy,
• Concomitant alcohol ingestion sweaty and/or itchy skin, pallor, anxiety,
• Adrenal suppression from oral corticosteroids light‑headedness, and shock
• Previous anaphylactic reactions • Neurological: uneasiness, weakness, seizures,
dizziness, confusion, syncope seizure, fear of
Persons with asthma, or with a history of sys- impending death, throbbing headache, altered
temic reactions or anaphylaxis, should be care- mental status, tunnel vision, and coma
fully selected and given immunotherapy with
particular caution. Those with asthma are a high Anaphylaxis produces bronchoconstriction,
risk for anaphylaxis though systemic reactions to vasodilation, and an increase in capillary perme-
immunotherapy only occur in 0.5% of cases; 50% ability. Breathing is compromised by swelling of
of these cases involved individuals with asthma the upper airway and narrowing of the bronchi.
[175–178]. Therefore, education and avoidance Vasodilation and increased capillary permeabil-
measures are integral to any prevention program. ity lower blood pressure. Fluids and proteins shift
More adults than children and more women into the interstitial space, and lack of sufficient
than men have risk factors for anaphylaxis. fluid volume and increased cardiac output pro-
Recent parenteral exposure rather than the oral duce shock. The changes in the capillaries also
route is most likely cause to trigger anaphylaxis. produce a swelling of the entire body, a charac-
Atopy and systemic mastocytosis are also con- teristic of anaphylaxis.
sidered risk factors [179]. If left untreated, anaphylaxis results in death
from asphyxiation, secondary to edema of the
upper airway, leading to total airway obstruction.
9.13.4 Symptoms The majority of those who die from anaphylactic
reactions do so due to respiratory complications,
The most common form of anaphylaxis is IgE and about one in four die as a result of cardiovas-
mediated and is the result of the interaction of the cular problems. Anaphylaxis has few intermedi-
antigen, specific IgE molecules, and mast cells ate outcomes. There is a real risk that the person
[180]. Mast cells line those areas of the body that might die; therefore, concerns about minor side
come into contact with the outside world and effects of epinephrine injection should be ignored
hence are to be found in the respiratory tract, in the interest of urgent treatment.
skin, ears, eyes, nose, mouth, and gastrointestinal
tract. Symptoms are seen in these areas and can 9.13.4.1 Biphasic Reactions
be grouped thus [165]: Each individual has a specific pattern of anaphy-
laxis that occurs in a similar fashion with each
• Cutaneous: angioedema, urticaria, and episode. Severity is also fairly consistent from
pruritis one episode to another. Thus, progression from
• Respiratory: rhinorrhea, tearing, sneezing, mild reactions to life‑threatening reactions, while
laryngeal edema, congestion, cough, conjunc- unusual, is not unknown.
There are some unusual, but important, pat- slowly). And radiocontrast materials and opiates
terns including biphasic and prolonged attacks, may lead to anaphylactoid reactions, such as
which occur in perhaps the fifth of episodes. warmth and flushing, by causing the release of
There may be an initial response to treatment fol- mediators.
lowed by a relapse, as severe as at presentation,
5–8 hours later. For this reason, prolonged obser- Swollen eyelids These may occur for many
vation, by medical personnel, is needed after reasons.
anaphylaxis.
Nonorganic disease This condition is the most
difficult to differentiate and varies from frank
9.13.5 Differential Diagnosis malingering to panic attacks and subtle disorders
of Anaphylaxis such as vocal cord dysfunction. Links between the
immune and nervous systems may be relevant.
The life‑threatening nature of anaphylaxis makes
it important that the healthcare professional be Rare syndromes Some rare syndromes may lead
able to recognize, identify, and act quickly. to overproduction of histamine. These include
However, alternative diagnoses must also be con- systemic mastocytosis, urticaria pigmentosa, and
sidered, including [170, 173]: some forms of leukemia.
Vasovagal attacks (faints) These occur in other- Other possible alternate diagnoses These
wise healthy individuals. In response to stress, include insulin reactions and myocardial infarction.
there is both hypotension and bradycardia lead-
ing to sudden loss of consciousness. In other
words, the person faints, but recovery is rapid. 9.13.6 Management of Anaphylaxis
Hereditary angioedema This is rare; swelling Anaphylaxis is treated with adrenaline (epineph-
may involve any part of the body, and hives do rine) [180, 181]. When a person goes into ana-
not occur. It can involve both the upper respira- phylactic shock, hypotension causes collapse.
tory tract and the gastrointestinal tract. The diag- Treatment using an epinephrine autoinjector is
nosis is made by measuring for C1 esterase described below.
deficiency.
• At the first sign of anaphylaxis, ease the per-
Chronic urticaria and angioedema Some indi- son on to the floor, keeping them on their side.
viduals may have recurrent urticaria and angio- (Or, use the Trendelenburg position.) Raise
edema, but the symptoms are usually mild. their feet off the floor.
• Straddle the person facing their feet. Do not
Restaurant syndrome Substances associated put any weight on them.
with collapse in restaurants include monosodium • Inject the epinephrine into the fleshy part of
glutamate, sulfites, and histamine in some fish. the thigh. With one hand, remove the cover
from the injector. Place that same hand on the
Drug reactions Medications may produce many person’s thigh, and holding the thigh firmly,
reactions in addition to anaphylaxis. For exam- use the other hand to press the tip down into
ple, angiotensin converting enzyme (ACE) inhib- the thigh.
itors may produce cough and angioedema. Local • Hold the person firmly since they will tend to
anesthetics commonly produce adverse reactions push the hand away and prevent the injection
such as tachycardia. Vancomycin may stimulate of epinephrine.
release of mediators (the red man syndrome pro- • If possible, ask someone else to hold the per-
duced can be prevented by infusing the drug son while injecting the epinephrine.
Evidence suggests epinephrine is more effec- injection of epinephrine may halt the reaction. If
tive if given intramuscularly than subcutaneously symptoms have not improved within 10 min, they
[182]. It is essential that the individual being may require another injection of epinephrine.
treated remains supine, preferably with the feet Hence, it is essential that epinephrine be avail-
higher than the head. Abrupt movement to the able and that medical help be at hand to cope with
upright position has been associated with sudden any delayed, prolonged, or biphasic reaction. In
death [165, 168, 183]. fatal cases, particularly those involving children,
Epinephrine, available in autoinjector devices, lack of supervision and lack of availability of epi-
is manufactured by a variety of companies and nephrine have been an issue. To prevent the
generally comes in two models—those for a biphasic reaction, many healthcare providers pre-
weight of 15 kg or less and those for a body scribe corticosteroids after the acute episode has
weight over 15 kg. Currently these include been treated with epinephrine.
Allerject, Auvi-Q, EpiPens, Impax, Symjepi, and
some generic models. Information on how to use
the different autoinjectors is available on the 9.13.7 Education for Anaphylaxis
respective company websites.
All epinephrine injectors are clearly marked Patient education for anaphylaxis requires that
with a best-before date. both the patient and the family:
These are the basic general instruction for the
use of the epinephrine autoinjectors. • Be able to identify the symptoms of
anaphylaxis.
• Remove the cap and follow instructions to • Understand the seriousness of the reaction.
unlock the mechanism. • Have epinephrine on hand, and know how to
• Place the appropriate end against the midsec- administer (or, if necessary, self‑administer) it.
tion of the thigh. • Know how to identify and avoid the allergen.
• Press down firmly or jab in and hold for 10 sec- • Involve other family members, friends, care-
onds (this activates the device and allows suf- givers, and relatives in the self‑care measures.
ficient time for the injection of medication). • Understand the disease process, particularly
• Call for emergency medical help. with reference to the biphasic component of
anaphylaxis.
Once the device has been used, handle it care- • Understand that the patient has to be kept
fully and give it to medical personnel for dis- lying down and not allowed to sit up.
posal. This also ensures that they know how • Understand the need for immediate medical
much epinephrine has been given. care.
These devices must be protected from heat. • Understand the need to wear medic-alert iden-
They should be kept at room temperature and not tification and to inform other healthcare per-
be allowed to freeze. sonnel, especially in case of emergency.
Epinephrine causes tremor and increased heart
rate. It may also cause anxiety, apprehension, While an expert panel developed a simple way
restlessness, tremor, weakness, dizziness, to remember the four basic steps required to care
sweating, pallor, nausea, vomiting, and head-
for a person with anaphylaxis, it can be used by
ache. Even when there is doubt as to whether the parents of children and individuals with allergies.
reaction is anaphylactic or not, it is essential to It is called SAFE [184]:
inject the adrenaline/epinephrine rather than S Seek support actively
wait. If the person is not having an anaphylactic A Allergens—identify and avoid them
reaction, the side effects will be obvious and will F Follow-up for specialty care
need to be monitored in a hospital. If they are E Epinephrine—keep on hand for
having an anaphylactic reaction, the speedy emergencies
Any education program must include training 3. Halfon N, Houtrow A, Larson K, Newacheck
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Part II
The Role of Education
An Integrated Approach to Asthma
Management
10
Contents
10.1 Overview 336
10.2 Asthma Management: A General Approach 336
10.2.1 Steps Taken by Healthcare Provider 336
10.2.2 Approach to Management: Role of Educator 337
10.2.3 Educational Visits 337
10.2.3.1 Initial Visit 337
10.2.3.2 Follow-Up Interview 341
10.2.3.3 Further Follow-up Appointments 344
10.3 Management of Problems by Age 345
10.3.1 Less than 1 Year 345
10.3.2 From 1 to 5 Years 346
10.3.3 From 5 to 12 Years 346
10.3.4 From 12 to 25 Years 346
10.3.5 From 25 to 35 Years 348
10.3.6 From 35 to 60 Years 348
10.3.7 Over 60 Years 348
10.4 Home Monitoring 348
10.4.1 The Peak Flow Meter 348
10.4.2 Calculating Diurnal Variability: Other Methods 351
10.4.2.1 Method 1 351
10.4.2.2 Method 2 351
10.4.2.3 Method 3 352
10.4.3 New Personal Best Readings 352
10.4.4 Checking PEF Technique 352
10.4.5 The Peak Flow Diary 353
10.4.6 Observing Symptoms and Using the Diary 354
10.4.7 The Asthma Action Plan 355
10.4.7.1 Acute Asthma 360
10.4.7.2 Other Approaches 360
10.5 Severe, Acute, and Chronic Asthma 362
10.6 Potentially Fatal Asthma 363
References 365
336 10 An Integrated Approach to Asthma Management
10.1 Overview
Key Points
• Both the healthcare provider and the Most professionals engaged in the management of
asthma educator have a role to play in asthma are very knowledgeable about some spe-
the management of an individual’s cific aspects of treatment but not about others.
asthma. Effective treatment and achievement of the best
• Establishing a procedure for both the results, however, requires a wider knowledge of the
initial visit and following visits allows subject, since the healthcare professional will need
the educator to build a relationship with to develop a unique combination of approaches
them and to facilitate education. while at the same time building an ongoing
• Management problems that are age relationship with the individual and/or family.

related are explored. Treatment can be suboptimal if attention is not paid
• Asthma can be managed at home using to the individual’s unique needs and milieu.
a peak flow meter, a peak flow diary, and This section describes how to integrate the
the use of an asthma action plan (AAP). many aspects of asthma management to achieve
• Examples of initial AAPs with symp- the best outcome for the individual.
toms and peak flow zones are provided.
• Modified AAP and an alternate, as sug-
gested by the 2020 Focused Update, are 10.2 Asthma Management:
shown. A General Approach
• Identifying severe, acute, and chronic
asthma is important. If asthma is to be managed well, it requires a
• Risk factors for potentially fatal asthma team approach, a partnership between the physi-
are discussed. cian or healthcare provider, the educator, and the
individual. Successful management requires that
all three be equally involved, each with a definite
and distinct role.
Chapter Objectives
After reading this chapter, you should be 10.2.1 Steps Taken by Healthcare
able to: Provider
1. Define the role of the physician or

The physician or healthcare provider must:
healthcare provider and that of the edu-
cator, in the management of asthma. 1. Review the history of:
2. List the information that you must obtain • Symptoms.
from an individual with asthma during • Seasonality of asthma
the first and subsequent visits to the clinic. • Time of day when symptoms are most
3. Discuss the management problems and obvious
challenges of asthma for different age • The current environment (home, school,
groups. work)
4. Explain how to use a peak flow meter, This will highlight any environmental
calculate variability, chart a peak flow factors that are causing chronic inflamma-
diary, and then present and interpret the tion. It should then lead to an important
results for the individual with asthma or discussion on the role of environmental
their family. avoidance or modification in the manage-
5. Devise an asthma action plan according ment of asthma.
to the healthcare provider’s prescription. 2. Review in great detail the most recent attack
and other episodes of severe deterioration.
This may allow further identification of the 10.2.3.1 Initial Visit

specific factors that are exacerbating the The educator must keep in mind the fact that
asthma. Such identification is not always easy, some people newly diagnosed with asthma may
as the early/late dual response to allergens remain in a state of denial for some time.
may be confusing (see Chap. 2). However, it is Individuals may still be attempting to come to
yet another opportunity to discuss environ- terms all the implications of having asthma and,
mental issues. hence, not in any mood to listen. They may be
3. Assess willingness and ability to comply with angry, frightened, searching for answers, and not
treatment suggestions. When the assessment emotionally prepared to meet with an educator.
is complete, written instructions (prepared by There may be resentment at the need to meet an
the healthcare provider, with the active coop- educator. Others may have known of the diagno-
eration of the person) will reinforce the sug- sis of asthma for years but be uncertain whether
gestions and improve adherence. an educator can help them.
4. Prescribe appropriate medication to be used to All encounters will have challenges, and some
relieve symptoms. will prove more difficult than others. The specif-
5. Devise an appropriate long-term treatment
ics will vary, but all of them will have worries,
plan that includes medication and environ- concerns, and questions. Therefore, very early in
mental avoidance strategies. For medications, that first meeting, it is essential that the educator
the plan must include the use of an appropri- explain:
ate device and teaching the use of that device.
6. Design an intervention plan (an asthma action • Why the educator is involved.
plan) for use when deterioration occurs. This • The immediate and long-term benefits of
action plan will complement the day-to-day knowing about asthma.
written instructions. • How they can achieve a life that is as symptom-
free as possible and be as active as they wish.
10.2.2 Approach to Management: Needless to say, the approach will have to be

Role of Educator tailored to meet each person’s specific needs. The
educator must assess their physical and emo-
The educator must collaborate with the prescriber tional states as well as level of asthma knowl-
to ensure an optimal result for the individual with edge, before giving any explanation. In other
asthma. Current studies clearly state the financial words, they must determine the person’s needs
benefits of education: when the person with asthma during that initial visit.
is taught by an educator about asthma care,
asthma control and quality of life increases while
asthma costs decrease. Those with asthma become
Points to Ponder
more self-reliant, and the skills developed as a
result of education are revealed in their confidence In the airways, asthma causes:
and their ability to manage the disease. These ben-
efits can directly be attributed to proper asthma • Inflammation of the lining
education, provided by a trained educator [1–4]. • Constriction of the muscles
• Increase in mucus production
• Remodeling
10.2.3 Educational Visits
Proper education cannot be achieved in one visit.

A number of training and teaching sessions with During the initial visit, the educator should do
the educator will be needed. all of the following:
1 . Collect background data. need or request. Ask questions, listen, and ensure
2. Assess asthma knowledge and provide any
that the information provided is fully understood.
needed and appropriate asthma information.
3. Decide on an educational approach and commu-
nication strategy (with the person and family). Points to Ponder
4. Obtain and record pre- and post-bronchodilator
peak expiratory flow readings (PEFs). Teaching the use of the peak flow meter:
5. Test for exercise-induced PEF variability (if
required). 1 . Explain how to use the meter
6. Request and review the prescription from the 2. Demonstrate how to use the meter
healthcare provider. 3. Have the person use the meter
7. Briefly explain the use and purpose of the 4. Correct any errors they made
medications, and invite questions. 5. Repeat Steps 3 and 4 as required
8. Provide initial information about how to con-
trol the asthma and improve the environment.
9. Prepare a follow-up plan that meets the indi-
vidual’s desires and needs. Collect the following date during the first
visit:
Consider each of these in turn.
• Height and weight
Step 1 Through 3: Meet, Reassure, Inform, –– Both are essential indicators for children
Collect, and Assess Information and should be plotted on a growth curve.
The asthma educator has to establish rapport, –– Obesity is an important condition that can
address concerns, provide reassurance, and collect complicate asthma management.
background information during the first meeting. • Past medical history, including any atopic dis-
The initial visit will be a long one, so extra time ease at any time in life
should be scheduled for any unforeseen tests or • Family history of asthma
other requirements and to address their concerns. • Current lifestyle
The educator should start by creating a relaxed • Occupation
atmosphere to put the person with asthma at ease • Environment
and establish an initial rapport. Address concerns • Symptoms
and provide reassurance if needed. • Known triggers
Most individuals will be scared, uncertain, and
in need of answers and reassurance. But they will Environmental data should include:
not turn to the educator for help until a link, how-
ever tenuous, has been established. Tact and peo- • The number of people in the home
ple-handling skills are essential, particularly for • Family’s economic position (well-off, middle-
that first visit. There is no predetermined method class, poor)
for successful interaction with an individual, and • Smokers in the house and smoking habits
the educator will have to use an approach that • Age and type of home and whether rented or
meets their needs. Steps 1 and 2 go together but not owned
necessarily in that order. On some occasions, infor- • Type of heating and air-conditioning
mation may need to be provided before establish- • Location: whether urban, suburban, or rural
ing communication; in other instances, both steps • Number and kind of pets
can be performed concurrently. Hence, it may • Occupation and other leisure activities
make sense to ask them what they hope to achieve • Whether other family members understand
or obtain from this first session and whether they the need and relevance for avoidance mea-
have any specific asthma-related goals. sures, their willingness to implement these
Information overload occurs very easily. measures, and their likely attitude to imple-
Provide only as much relevant information as they mentation of these measures
Ask what is their biggest concern or worry, and if about 15–20 minutes after—will indicate the degree
we can only improve one thing, what would it be? of reversibility for the person on that particular day.
Ask questions that are open ended – ask in such Most individuals new to asthma will be totally unfa-
a way that the person with asthma will tell you in miliar with the peak flow meter (PFM). Take the
detail about the man symptoms. Questions should time to explain what it is, how it works, and what it
not be asked in a fixed sequence – start with asking measures – after all, this is the diagnostic tool that
about the main concerns, then move flexibly they will rely on and use most often. They need to
through the various topics. be carefully taught how to use the PFM.
Demonstrate how to use the meter. Tell them
Examples that you are using a disposable mouthpiece and
that the meter they buy will not have such a
• What time of day do you have the most trou- mouthpiece. Let them get comfortable with hold-
ble e.g. when first wakening, during the day, ing it and using it. After they have done this,
evening or over night? Whatever the response, obtain a standard best-of-three PEF reading.
it will trigger other questions and will help to Before obtaining the first reading, check with
determine the order of questions. them to see if they have used a bronchodilator
• Do you have chest problems (cough, chest within the last 4 hours (PEFs after a bronchodila-
tightness, wheeze, etc.) when you wake up? tor will give only limited information and should
They may talk about shortness of breath: this is be deferred. If so, set up another appointment,
another trigger for exploratory questions. What and remind them to avoid use of a bronchodilator
does shortness of breath or difficulty in breath- if possible during the 4-hour period prior to that
ing mean to each individual? Is it difficulty in visit).
taking a deep breath in? A deep breath out? Ask Administer the bronchodilator and wait for
if they have difficulty taking a full, deep breath. 15–20 minutes. Use the waiting time to complete
• Do you wheeze? (An explanation of what your data collection or answer questions, as appro-
wheeze is may be required.) priate. Then, obtain the second set of PEFs. Step 3
• Is ordinary exercise – e.g. housework or gar- (recording of basic medical and personal data)
dening – a problem? Do you have trouble may be performed during this waiting period.
climbing stairs? Is exercising in a gym becom- Record the PEF on the standard chart that the
ing a problem? Is there cough on exercise? clinic is using. If the person has never seen such
• Do you sometimes have difficulty breathing? a chart before, take the time to explain how the
• Do you have trouble going to sleep? readings are recorded and what the various num-
• How many pillows do you use at night? bers mean.
• Do you wake up in the middle of the night? If they are unfamiliar with the simple graph-
• Do you have trouble sleeping at night? ing system used on the chart, explain that also
• Do you know what wakes you during the night? (since they will, at some time, be asked to record
and graph personal PEFs while at home, it is
Again, data collection does not have to be important that they understand the PEF recording
done in any fixed sequence. The information process and how it helps monitor the asthma).
should be obtained at an appropriate time during
the first visit. While this is going on, formulate an • Tell them when, how often, and for how many
initial teaching strategy—what is the best days the readings must be taken and charted.
approach to use with this particular person. Make PEF readings should only be taken when
a note of it after the meeting. standing or sitting upright but not lying down
[5] (see the ten-step protocol for teaching the
Step 4: Obtain PEFs use of a PEFM later in this chapter).
Two peak expiratory flow (PEF) readings—one • Explain the red, yellow, and green zones.
before administering a bronchodilator and one Explain how, over a period of 2 weeks, per-
sonal zones can be established and used as a ways. Relievers only relieve symptoms and do
quick indicator of the state of asthma at any not affect the underlying inflammation.
time (see protocol for teaching PEF with • Stress that long-acting bronchodilator dosages
zones). may not be increased and should not be used
for symptom control.
This is a good time to assess the level of sever- • Take as much time as required to ensure that
ity based on their symptoms and peak flows. the individual knows how to use the device
correctly. Ask them to demonstrate by using a
Step 5: Test for Exercise-Induced PEF placebo, and correct any errors made. This
Variability will reinforce the correct method. This is
If needed, perform a test for exercise-induced known as the “teach-back method” and is
PEF variability. See Chap. 3 for details. effective in clarifying how much they have
understood.
Steps 6 and 7: Request and Review the • Answer any other questions regarding the
Prescription treatment, and provide any other information
At this point, review the prescription with the if requested.
person. Ensure that they do have a prescription.
Ask them whether or not there will be any finan- Provide initial information about how to con-
cial difficulty in filling the prescription. To a per- trol the asthma and improve the environment.
son who is new to the country, explain how to fill This includes help with setting up a daily readings
the prescription. and medication schedule, indicating when and
how often PEF readings and the medications are
Step 8: Medications, Environmental Control, to be taken. This is the asthma action plan (AAP),
and the Asthma Action Plan which should contain the written information
Discuss the prescribed medications with the indi- about the medication to be taken (when, how
vidual with asthma. often, possible side effects to watch for) and a
telephone number for contact during office hours.
• Talk about relievers and controllers. They must call if any of the following occur:
• If necessary, explain the difference between
the illegal steroids taken by athletes and the • The actual amount of medication required to
corticosteroids that have been prescribed. handle symptoms is greater than that
• Stress the fact that they must not stop taking prescribed.
controller medications simply because symp- • Side effects are experienced that are notice-
toms are no longer present. Controller medi- able, lasting, or generate discomfort.
cations actually keep them well. (A simple • Emergency care is required.
analogy would be the daily brushing of teeth
to prevent cavities: people do not start brush- Emergency care symptoms are those that
ing their teeth after they have developed a cav- require immediate professional help, whether
ity; rather, they brush daily to help prevent through a visit to the healthcare provider or to a
cavities from forming.) Controller medication hospital. Explain or describe these signs and
prevents inflammation from becoming severe. symptoms (see Table 1.1 in Chap. 1). Give them
If taken only when symptoms appear, the the name of a hospital or clinic, where help out-
inflammation would require much more medi- side office hours and during weekends is avail-
cation to control. able. Tell them what to say to the healthcare
• Stress that controllers require time to work provider there and what information to
(tell them how much time is required for their provide.
particular medication to become effective) If their triggers are known, explain how to
whereas relievers work instantly to relax air- avoid or eliminate them. Help them determine
what should be done immediately, and list the During the follow-up interview:
steps in order of priority. Give them written infor-
mation on trigger avoidance. Discuss how this 1 . Review progress since the previous meeting.
can be implemented. 2. Confirm adherence to the medication regime.
Keep explanations simple but adequate. Make 3. Confirm correct device technique.
suggestions, but let them make the final decision. 4. Ask for difficulties encountered with the

Do not expect them to implement all the sugges- AAP.
tions pertaining to environmental control. If they 5. Review environmental controls, and note the
choose just one item and commit to doing it, that changes made and difficulties encountered.
is a good beginning. Allow them to choose what Changes can be positive (triggers are being
is to be done first of all. Allowing them to make a avoided) or negative (new triggers have been
choice helps give them a sense of control. Provide identified).
them with brochures or leaflets on asthma at the 6. Discuss the possibility of medication changes
required level of literacy. with the healthcare provider, if necessary.
You should previously have reviewed these 7. Explain all changes to the person, and provide
items to ensure they are appropriate, accurate, a written update.
and that they use clear simple language. The best 8.
Answer questions, and book the next
pamphlets are initially written by professionals appointment.
knowledgeable about asthma, then rewritten by
writers skilled in reaching an audience with a Unlike the initial interview, where the event
wide range of educational achievements, and sequence may vary to some extent, these eight
then finally reviewed by a cross section of those steps should be performed in the sequence shown.
with asthma. Brochures that do not follow these Since the follow-up interview is a logical contin-
steps are less than useless. uation of treatment, the person will feel reassured
(and more comfortable) if it is carried out in a
Step 9: Follow-Up Plan and Conclusion logical manner.
Briefly review what has been covered in this ses-
sion. Then: Step 1: Review Progress
Check on symptoms and the PEF diary. Have any
• Review and repeat the actions they must take. symptoms changed? Are any new symptoms pres-
• Reinforce the goals that are to be achieved ent? Is the diary well maintained or incomplete? Is
within a certain time frame. recordkeeping posing a problem? Has the person
understood the action plans? If the individual needs
Finally, ask them if they have any other con- help, provide suggestions, or show examples.
cerns or questions. Discuss them. Then, book a As before, ask whether the person’s earlier
return appointment, to take place usually in a symptoms remain unchanged. If they have
week or two (Figs. 10.1 and 10.2). changed, in what way? Ask them to describe the
symptoms. Ask, too, if there is any change in the
10.2.3.2 Follow-Up Interview environment at work or at home or with the fam-
At the initial interview, an individual’s history ily. Are there any concerns to be discussed? Have
and list of symptoms was obtained. Review that any new triggers been identified? Have their
information prior to the follow-up meeting. goals (from the previous session) been met? Are
Reference made to the information obtained at there any new goals? What would be a good out-
the previous visit will increase credibility. come for this session?
Note that the self-management plan is also
referred to as the asthma action plan (AAP). Use Step 2: Confirm Adherence to Medication
the words asthma action plan in all discussions, Confirm that the medications are being taken as
as this reinforces the need for action. prescribed. Has the medication helped? Ask
1. Find out if the person already knows what a 6. Help them to practice. Ask them to:
peak flow meter is used for a) Read the number on the scale.
a) If no, proceed to Step 2. b) Mark the number on the chart.
b) If yes, proceed to Step 3. c) Use the PEFM twice more and mark the
best of three readings on the chart.
2. Use visual aids, and provide the following
explanations: 7. Obtain feedback. Ask them to tell you
a) The PEFM measures how fast one can a) What a PEFM is used for.
blow air out of the airways. b) When the readings should be taken.
b) In asthma, the airways narrow because c) What sort of pattern will be seen between
of swelling and extra mucus, and because the morning and evening readings.
the muscles around the airway go into
spasm or tighten. So, just as a thermometer 8. Provide additional information
is used to measure a fever, the PEFM tells a) Correct misunderstandings. Repeat step 2
if needed.
how much the airways are irritated and
b) Tell them how long to use the PEF meter
swollen.
(generally, two weeks).
c) Readings are usually taken first thing in
c) Explain that the time is required to
the morning and again at night. Explain establish a personal baseline.
that the morning reading is generally
lower than the evening reading and that 9. Answer questions
this is normal. a) Ask for questions. Answer them.
b) Confirm that it will be possible to measure
3. Explain how to use a PEFM, using a simple PEF every morning and evening at the
explanation similar to this: same time each day. Determine if there will
a) “Stand up (preferable) or sit up straight.” be any difficulties in doing so.
b) “Place the pointer at zero.” c) Help them devise a simple “memory aid” to
c) “Take a deep breath.” remember to take a PEF. (Perhaps before
d) “Place the PEFM in your mouth brushing the teeth in the morning and after
between your lips, on your tongue and getting ready for bed at night.)
beyond your teeth.” d) Remind them to stand up when taking the
e) “Seal your lips around the mouthpiece.” readings.
f) “Blow as hard and as fast as you can.” e) Confirm that they are capable of charting
g) “Record the number on the chart.” the readings.
f) Explain why readings are needed for the
next two weeks.
4. Demonstrate the above steps. Explain that the
PEFM does not measure how long but
10. Follow-up visit
how fast you breathe out. a) Book a return visit for two weeks. Give
them a card showing the date and time,
5. Ask the person to demonstrate the use of and a phone number where you can be
the PEFM to you. reached.
a) Change the mouthpiece. Hand the b) Ensure that they have a PEFM and a dairy chart.
c) Tell them to contact you by phone if they
PEFM to the person.
have any questions.
b) Remind them to reset the pointer. d) Explain how (or if) you use voice-mail and how
c) Observe their technique carefully and soon calls are usually returned.
e) If necessary, provide your e-mail address as an
correct where necessary. Praise if
alternate way to reach you.
correct.
Fig. 10.1 Ten-step protocol for teaching the use of a peak flow meter. (©The Asthma Education Clinic Ltd)
about any concerns, and if any, explore them in Step 3: Confirm Correct Use of Devices
detail. Questions such as: “What do you dislike Check that the PFM and the prescribed medica-
most about taking this medication?” and “About tion device are being used correctly. Ask them to
how many times did you forget to take your med- demonstrate their use. Provide positive reinforce-
icine last week?” are more likely to elicit infor- ment (praise for the things done correctly, gentle
mation than those that can be answered with a correction of the things done wrong). Have them
simple yes or no. This last question also indicates practice in the office until the device is used cor-
that individuals will lapse occasionally and in rectly. Remember that medication is not much
effect gives them “permission” to talk about the good if it is not being inhaled correctly due to
lapses. poor technique.
Steps 1-9 c) Explain the zones.

d) Describe what should be done if readings
Explain Steps 1 through 9 of the “Ten-Step go into the yellow zone.
Protocol for Teaching the Use of a Peak Flow e) Describe what should be done if readings
Meter”. (See preceding Figure 9-1.) Then, go into the red zone.
continue with steps 10 through 14 below.
12. Provide feedback, and answer questions
_______ a) Correct the person if necessary. Repeat
information from step 10 if needed.
10. Use visual aids b) Ask if there are any questions and answer
a) Explain the three zones and what they them.
mean: c) Is there anything else she or he would
- the green zone indicates a reading that is like to know?
80% or more of the person’s best effort
and it means their airways are open and 13. Concluding instructions
they need have no concerns in that a) Tell them to contact you by phone if they
regard. have any concerns. Should peak flows
- the yellow zone is a reading between drop into the yellow zone, they are to call
51% and 79%. Theyt should be careful. you after taking the appropriate action
There is inflammation or swelling in the according to the action plan.
airways. They must respond by taking b) Ensure that they have a PEFM, a dairy
medications according to their personal chart and an asthma action plan.
asthma action plan. c) Check that they have sufficient
- the red zone indicates a reading of 50% medication to last till the return visit,
or less. They need – must get – medical including the changes in dosage of the
help immediately by calling their doctor medication required by the asthma action
or going to the nearest hospital. plan.
b) Compare the zones with the traffic lights:
green means go, yellow is a warning, and 14. Follow-up visit
red means danger. a) Book a return visit for two weeks. Give
c) Draw a PEF graph that drops in and out them a card showing the date and time,
of the three zones and explain to the and a phone number where you can be
individual how to interpret it. Remind reached.
them that this is only a sample graph, b) Ensure that the person has a PEFM and a
strictly for illustrative purposes — it does dairy chart.
not show the person’s personal readings. c) Tell them to contact you by phone if she
d) Show how the three zones are linked to or he has any questions.
the steps of the asthma action plan. d) Explain how (or if) you use voice-mail
e) Review the person’s personal asthma and how soon calls are usually returned.
action plan. e) If necessary, provide your e-mail address
as an alternate way to reach you
11. Obtain feedback
Ask them to use his/her own words and:
a) Explain what the PEF meter is used for.
b) Explain how the PEF can help monitor
the airways.
Fig. 10.2 Protocol for teaching how to use PEF zones for self-monitoring. (©The Asthma Education Clinic Ltd)
This is also a good time to: • Check if they know where the expiration date
are printed.
• Find out how and where the device is nor- • Ascertain how many inhalers they are using
mally stored. (some use two or more inhalers concur-
• Confirm that they know how to clean and care rently, and store them in different
for it. locations).
• Check if they are monitoring the number of The search for triggers or changes in triggers
doses remaining in the inhaler(s). should be discussed at every visit.
• Review and (if necessary) change the number
and frequency of PEFs taken. Step 6: Changes to Medications (If
Necessary)
Step 4: Check for Adherence and Any If the medication needs to be changed, find a time
Problems with the AAP when you and the prescriber can talk. Promise to
Determine if there are any problems with: get back to the person with asthma as soon as
possible. The prescriber may change the medica-
• The personalized AAP tion and modify or approve any changes to the
• The medication regimen AAP. Email is not a suitable way to communicate
• Side effects from the medication due to its lack of security regarding confidential-
ity. It is helpful to establish cooperative relation-
Based on the individual’s comments and the ships between the various individuals helping
review of the PEF diary, the AAP may have to be someone with asthma, and if it is possible, a
modified or a change in medication considered in secure messaging system can be extremely
consultation with the physician or healthcare helpful.
provider.
Review the notes from the first appointment, Step 7: Explain the Changes
since there may be some items that should be Present and explain the changes. Also explain
taken into consideration when modifying the why they were made and how long before the
AAP. benefits of any new medication will be felt.
Provide a written update to the personal asthma
Step 5: Review Environmental Control action plan. Explain the reason for the updates. If
During the first interview, you may have sug- needed, provide leaflets and more detailed infor-
gested one or more environmental changes to mation at the appropriate reading level.
minimize the effect of triggers. In this step:
Step 8: Review and Answer Questions
• Find out if the changes that they chose were Review what they have done to date, provide
made. reinforcement and encouragement for what has
• Inquire about problems encountered in mak- been achieved, and reiterate what must be done to
ing those changes. achieve the next mutually agreed goal. Finally,
• If necessary, suggest alternatives. ask if they have any concerns or questions, and
• Record comments and any (new) suggestions. take time to discuss them. Book a return appoint-
• Determine whether any environmental or ment as required.
other changes have occurred in their life. At
home there might be a new pet or renovations 10.2.3.3 Further Follow-up
done. At school, the person at the next desk Appointments
may use perfume. At work, new substances Appointment frequency will depend on two fac-
or even equipment may have been tors: the objective severity of the asthma, as
introduced. determined by the asthma educator, and their per-
sonal needs, i.e., severity as estimated by the
Remind them that: individual.
As mentioned earlier, the first follow-up
• Avoidance of triggers is the key to asthma appointment should take place about 1 week after
control. the first visit. Some individuals will require a sec-
• They must learn to actively monitor the ond appointment 2 weeks after the follow-up visit
environment. in order to ensure that their asthma is under control.
• They must know their personal triggers. They should be reminded that asthma symptoms
will change from time to time and that their AAP a specialist and make the necessary referral.
will need to be updated on a regular basis. Refer to the physician all those who:
Medical follow-up is essential, preferably with
the same healthcare provider. Any change in • Do not respond to the prescribed treatment
symptoms or any reactions to the medication • Have had a recent severe attack
must be reported. • Require oral steroids
For mild asthma, generally speaking, a • Suffer serious side effects from the
yearly checkup by the healthcare provider, fol- medication
lowed by a quick review by the educator, may • Require a differential diagnosis
suffice. Persons with seasonal asthma should be • Are having a serious asthma attack
seen about a month prior to the season so that • Refuse to comply or work with the educator
appropriate medication can be prescribed. For
the person with well-controlled but chronic If there are any concerns about the individu-
asthma, appointments every 3–4 months should al’s self-management, refer them to the physician
suffice. or the prescriber who is ultimately responsible
In acute exacerbations, individuals with for the individual.
asthma should follow their AAP. When they first
start using an AAP, they should be encouraged to
confirm their response (i.e., their actions) with 10.3 Management of Problems
the educator. As their confidence increases, this by Age
need will diminish. Sometimes, when they phone
for advice, it will be obvious that the exacerba- Although a general approach to asthma manage-
tion is severe, and they should be told to see their ment may be followed in most cases, there are
healthcare provider immediately. Individuals specific problems with each age group that must
with asthma who have recently been admitted to be borne in mind.
hospital should see their healthcare provider
within a week or so of going home.
Initially, after a diagnosis, there may be fear 10.3.1 Less than 1 Year
about changing doses of medication or adding
medications, even if it is written in an AAP. Help Onset of asthma at this age is possible but uncom-
is often needed in making the appropriate deci- mon. Even after several attacks of an illness that
sions, particularly when they are having symp- seems to be asthma, it may turn out that the diag-
toms. Doing a “dry run” or a practice “medical nosis is something else. The asthma educator
emergency” in the educator’s office, where the must be alert to this possibility and maintain
AAP is consulted and its recommendations are close liaison with the child’s healthcare provider
followed, provides anticipatory guidance that while encouraging the parents to do the same.
makes them realize that the AAP plan tells them The specific problems leading to management
what to do and when to do it. This is particularly difficulties are:
helpful with young children since family mem-
bers can be assigned roles, and this reduces the • Rapid deterioration
fear that accompanies an exacerbation and gives • Difficulty in administering medication
them a sense of control when a genuine situation • Determining exactly when to administer
arises later, at home. medication
Encourage them to contact the clinic if they
have any questions or concerns. Be prepared to Rapid deterioration commonly occurs with
provide advice by phone and to handle all types the frequent viral infections of infancy. The child
of situations, either personally or by referral to with asthma may go from good health to having
the healthcare provider, who may see the need for extreme dyspnea in just a few hours. Peak flow
meters or spirometry cannot be used to predict during deterioration, but this is the only real limi-
deterioration, and admission to hospital often tation. Children of this age will be able to employ
occurs because of the rapid onset, severity of epi- a peak flow meter, but PEF measurements are not
sodes, and need for oxygen therapy. sensitive enough to register changes in lung func-
There are major difficulties in administering tion [6]. PEF readings correlate poorly with spi-
medication at this age. The airway geometry, the rometry readings. For moderate to severe cases,
size of the airway, and the branching pattern make PEF should be combined with a symptom diary
it difficult for inhaled medication to reach medium and a medication use dairy.
and small airways in effective concentrations. Children in this age group will be able to make
The obvious problems include those of enlist- suggestions as to their own management and be
ing the cooperation of the child and in ensuring able to express desires for a particular sporting
that the child will sit still during prophylactic activity. However, they are unable to correlate
treatment. The first choice is to use a metered symptoms with inability to function normally.
dose inhaler and a spacer to deliver medication to There is a wide range of perceptual accuracy [7].
infants. Often a nebulizer is used, but some Problems with adherence are not thought to be
infants develop an aversion to the nebulizer, and common but certainly occur. For many children,
the equipment, while expensive, also delivers a the discipline of daily treatment can become a
high dosage of drug. Oral medication might seem game. The major difficulty with adherence is
an easy way to avoid the use of a metered dose avoiding those environments that could trigger
inhaler or nebulized medication, but the medica- asthma. There are major problems if there is a pet
tions given by mouth have many drawbacks. in the classroom or if a friend has a pet.
Theophylline requires blood levels to be moni-
tored and causes behavioral changes. Oral bron-
chodilators quite often induce hyperactivity. 10.3.4 From 12 to 25 Years
Parents can be taught and encouraged to
observe attacks closely, to note symptoms of In many ways this group should be the easiest to
deterioration, and to modify standard symptom manage. However, the continuing incidence of
scores in order to develop one for use with their morbidity (as measured by emergency depart-
child. It requires time and experience before par- ment visits and hospital admissions) would indi-
ents learn when to initiate treatment as their cate that this is far from true [8]. Mortality is low
child’s asthma deteriorates. in asthma, but the most common age group in
which death occurs is in the 15–29-year range [9].
Diagnosis is usually easy, and individuals in
10.3.2 From 1 to 5 Years this age can be taught to use the devices and a
peak flow meter. Their major problems are those
In this group there is still a problem with rapidity of adherence with regular treatment. Denial is
of deterioration and also a problem in administer- common, specifically denial of:
ing the drug. However, it is easier to use a MDI
with a spacer, and there are often more warning • Symptoms
signs than in younger children. • Deterioration
• The need to avoid triggers
• The very presence of the disease
10.3.3 From 5 to 12 Years
Smoking begins at this age, often as an act of
There are fewer diagnostic problems with recur- rebellion, but the addictive power of nicotine
rent cough and wheeze than there are in younger means that most of those who start will continue.
children, and these children can use most devices. Children with asthma are as likely to start smok-
Some of the dry powder devices cannot be used ing as anyone else.
while direct criticism should be avoided, the edu-

Points to Ponder cator can mention that they did take a risk.
A program to reduce exposure to tobacco Careers are chosen at this age. Any discussion
smoke is more likely to be successful than on career choices requires openness, and jobs
a total ban. that are likely to cause problems in asthma should
be identified. Students with less education may
have fewer occupational choices, and economic
necessity may force them into jobs in smoky,
Vaping—a variation on smoking—has grown dusty, allergic environments.
exponentially in this age group due to clever mar-
keting of flavored nicotine. Packaging that makes
Case Study
the devices resemble flash drives or USB sticks
allows adolescents to hide them from teachers, Jane Little, who has had asthma for years,
parents, and other adults. Many adolescents are went to camp. She had an action plan, so
unaware of the dangers inherent in vaping, and that she could enjoy the experience without
the number using e-cigarettes (EC) almost tripled running into trouble with her asthma.
between 2013 and 2014 with 20.8% of high She comes to see you after she gets home.
school students using EC [10]. Forty percent of She is upset because her friends teased her
young adults vape and have never tried regular constantly about her snoring. The boys at
cigarettes [11]. A variety of techniques for inhal- the camp made fun of her runny nose that
ing nicotine from dipping to steeping allow users she rubs frequently. How can you help her?
to increase the dose of nicotine and accompany- ---
ing chemicals going to their lungs [12]. Allergic rhinitis is common in people
The educator dealing with teenagers should dis- with asthma, and snoring is common in peo-
cuss peer pressure, in general, and pressure to ple with allergic rhinitis. Jane may also have
smoke, in particular, and offer or present strategies nasal polyps, especially if she uses aspirin-
to help the person with asthma avoid starting to based analgesics. She needs to find out if she
smoke. For those who do start smoking, support snores at home (the family may be so used
needs to be provided to help them stop or to cut to her snoring that they no longer notice it).
down. Often it will be more acceptable and success- Review the bedroom environment with
ful to discuss reducing exposure than to require total her, simply because more time is spent in
prohibition, no matter how justified or tempting. the bedroom than in any other single room.
Even nonsmokers will be exposed to smoke. However, there are other rooms and envi-
Social activities at this age (and later) include bars ronments to consider. Is there a pet in the
where smoking is endemic, and this may lead to house? Is there exposure to smoke or mold
sharp deterioration. The educator must develop in the home or what about the school?
strategies with them to deal with such situations. Explore these issues. Advise her to avoid
It is worth noting that those with severe asthma analgesics with aspirin if she has pain—an
make no more effort to avoid secondhand smoke over-the-counter long-acting antihistamine
than those with mild asthma [13]. The educator may help her instead. Her family health-
must avoid being perceived as unduly critical. For care provider or pediatrician should per-
example, a young adult in the early stages of form a medical evaluation, and she may
asthma deterioration may go to a smoke-filled bar also benefit from nasal corticosteroids or
or nightspot without increasing, or even taking, from a visit to an ENT (ear, nose, and
asthma medication. It will require a great effort of throat) or allergy specialist. There may also
will for the educator to remain both silent and be issues of obstructive sleep apnea, requir-
supportive, but it is important that this be done so ing appropriate evaluation.
as to maintain the individual’s trust. Nonetheless,
10.3.5 From 25 to 35 Years There may be increasing psychomotor problems

with drug administration, and there may also be
Management is simpler in this group. The diag- memory problems, making adherence difficult.
nosis is easy, and these individuals can be taught
the use of most devices. There is less denial,
although it will persist. Also, they may, by this 10.4 Home Monitoring
age, be established, addicted smokers. The home
environment may be a problem. Spouses and 10.4.1 The Peak Flow Meter
partners may smoke or have pets, and negotiation
is important. Support may not be present. New The peak expiratory flow meter (PEFM) is a hand-
partners, friends, and colleagues will all require held device that measures, in liters per minute, the
education about asthma and its impact. speed at which air is expelled from the lungs. It is
The work environment may pose problems. safe, reliable, portable, and low in cost and pro-
Individuals who initially made an unwise career vides easily reproducible quantitative assessments
choice may already be showing deterioration. of airflow. Unfortunately, it is also easy to use
Again, economic necessity may result in the incorrectly and to hence obtain misleading results.
acceptance of an undesirable job. In this age In asthma, the physiological abnormality is in
group, previously healthy persons may begin to expiration. The peak flow meter provides a “snap-
suffer from occupational asthma, and this will be shot” of large airway function. Its use includes
an unwelcome surprise. They will need help and detecting the presence or absence of nocturnal
support if they need to change careers and to asthma [15]. During an attack, peak flows will
adjust to the practical realities that face them. decline before the onset of symptoms, at which
Availability of health benefits is an important point a decrease of about 30% occurs [16]. If the
consideration, particularly of an insurance plan attack is acute, deterioration in symptoms will be
that encourages a proactive approach to asthma. more noticeable and changes in peak flow less
sensitive. PEF is less sensitive and much less
accurate than FEV1 in estimating the degree of
10.3.6 From 35 to 60 Years obstruction. Although international guidelines
suggest that they are of equivalent usefulness in
The diagnosis is easily made and treatment can be estimating severity, this idea has been challenged
given using most devices. Coexisting diseases [17]. PEF is not helpful in determining the degree
become common, and interaction with other medi- of either inflammation or asthma control [18].
cation becomes a much more frequent problem. When used correctly, the PEFM is a useful
Persons with coexisting lung diseases pose particu- device. It:
lar problems. Smoking-related chronic obstructive
lung disease (COLD or COPD) and emphysema • Can be used at home and in the hospital
have some features in common with asthma, and • Objectively measures expiratory flow rate
some of the same medications may be used [14]. • Provides serial measurements
These diseases may coexist with asthma. • Predicts acute exacerbations or relapses
The important first step is to stop or reduce • Monitors the response to therapy
smoking. The general measures used in asthma • Identifies environmental precipitants of
may also be used in COLD, but the degree of asthma
reversibility is minimal if at all present.
Serial measurement of peak flows helps diag-
nosis and self-management [19]. PEF is at its
10.3.7 Over 60 Years highest around 4 p.m. and at its lowest at 4 a.m.,
and these are the ideal times when PEF should be
Problems of interaction with other diseases and taken. But since this is not practical for most indi-
with other medications will become more severe. viduals, readings are generally taken at morning
and night, even though the values obtained will

likely be an underestimation of the actual diurnal Case Study
variation. The NAEPP task force report [20] lays
Allis Martin has phoned you about her
emphasis on the morning PEF as a measure of air-
grandson. He is 14 years old and has
flow obstruction. The NHLBI guidelines [21] also
asthma. Normally he does not use a peak
suggest that the morning PEF be used for the pur-
flow meter, but she says that she can hear
pose of treatment guidelines in those with stable
him wheezing so she made him use her
asthma. Individuals whose asthma is not in control
peak flow meter. He blew 180 l/min. He
should increase the frequency of PEF monitoring.
plays trumpet in the school band and is
PEF readings must be taken with the person
involved in both basketball and football.
upright, preferably standing, or sitting. A reading
She wants to know what he should be blow-
taken in a supine position will be significantly
ing and feels that 180 is far too low since
lower [5]. Testing posture should be consistent
she normally blows in the 440 l/min range.
with all readings taken either standing up or sit-
How would you answer her?
ting upright. PEF readings are best recorded in
Ask her for all the symptoms her grand-
graph form within a diary. One picture is worth a
son is exhibiting and for how long he has
thousand words, and nowhere is this truer than
had them. Since the 180 reading on the
with PEF readings. When the readings are marked
peak flow is on her device and as he nor-
on a graph and the points are connected, slow
mally does not use a peak flow meter, she
unnoticed deterioration can easily be identified
should not be concerned with the reading,
long before other symptoms indicate a problem.
since it is not his machine and he has not
Each person should develop a “personal best”
been taught how to use one. There may be
peak flow reading. While the peak flow charts (see
a number of reasons why he blew only
Figs. 3.26 and 3.27 in Chap. 3) provide general
180. What matters are his symptoms and
guidelines of so-called “averages”, there is a very
these have to be considered.
wide variation in what would be considered nor-
mal. The only value to be followed is the person’s
personal-best PEF, recorded over a period of at
least 2 weeks [21]. For men the normal PEF lies PEF technique will deteriorate over time—
between 500 and 700 l/m, while women have a in as little as 3 weeks—and should hence be
range between 380 and 500 l/m. Unlike spirometry, checked at each visit. More importantly, since
variations in PEF for race, ethnicity, and smoking there is a wide variation in readings from dif-
are not standardized, but the tables of predicted val- ferent makes [22] and even between devices of
ues are corrected for age, sex, and height. They also the same brand [23], the asthma educator
include normal limits of diurnal variability [19]. should suggest bringing in their personal peak
PEF is dependent on effort, muscle strength, and flow meter to ensure that the readings are done
motivation. It also requires a deep inhalation, which on the same device. Any change in device
in some individuals may cause bronchoconstriction requires that the individual’s range be reestab-
and make them reluctant to provide a reading. As a lished for that model. To validate readings, it is
result, their PEF technique will vary from day to advisable to annually compare the results to
day, especially among individuals who have just results of a standard pulmonary function test.
started using the device. For this reason, PEFs A noticeable variation in the three attempts
should be recorded for at least 2 weeks (preferably taken by a person may also indicate a malfunc-
for 3 weeks), while their asthma is well controlled, tioning device [19]. However, if there is a
before a personal-best PEF can be determined. This steady fall in the three readings, this may be
may even require a trial of ICS therapy or systemic the result of increased lability and therefore
corticosteroids in order to get the asthma under imminent deterioration. If this happens, do not
control prior to finding the personal-best PEF. persist.
Once a PEF personal best reading is estab- • When peak flow readings fall below the
lished, then the objectives of therapy can be orange zone into the red zone (below 50%),
based on a percent of normal predicted value. they are required to seek emergency medical
Then and only then can calculations for the peak help immediately.
flow green, yellow, and red zones for each indi-
vidual be made as follows: This four-stage plan is extremely effective
Green zone: 80–100% (and above) of best with those who have severe asthma and who are
reading required to keep oral corticosteroids on hand for
Yellow zone: 50–79% of best reading sudden deterioration.
Red zone: Below 50% of best reading A reading of 50% below a personal best read-
The three zones—“green, yellow, and red”— ing indicates a severe asthma attack. Any person
are analogous to traffic lights and can best be with a peak flow reading at 33% of the personal
explained by comparing them to the actions indi- best is in a life-threatening situation and requires
cated by the lights. immediate hospitalization.
There are other certain factors in PEFs that
• Green indicates safety. The asthma is under should be brought to the attention of the
control. A normal life can be lived. individual:
• Yellow implies caution. The asthma is worsen-
ing, and precautionary steps should be taken • Diurnal variation: A variation between 10%
as outlined in the personal AAP. These will and 12% is normal, with morning readings
include increasing the dosage of controller lower than evening readings.
medications, using bronchodilators as • Daily variations greater than 15% indicate
required, and taking more care to avoid worsening asthma.
triggers.
• Red signals danger and imminent trouble. They should be told to begin using their PEFM
Medical help will be needed. Their physician at the very first symptom of deterioration and not
or healthcare provider must be contacted to wait till they are in distress. Once in distress,
immediately, or they should immediately go they will probably have insufficient breath and be
to the hospital. unwilling to use a PEF meter. A significant num-
ber of individuals substantially underestimate the
Some action plans use four-color zones severity of their asthma and place themselves at
instead of three: risk of increased morbidity and mortality [24].
PEF is particularly important for those who tend
• Green zone: 80–100% of best reading to underestimate the severity of airflow limitation
• Yellow zone: 60–79% of best reading [25, 26].
• Orange zone: 50–59% of best reading For those with moderate to severe asthma, the
• Red zone: Below 50% of best reading PEFM can be a useful tool [27]. However, its use
should be limited to short periods of time, simply
Here, the yellow zone from the three-color because most individuals do not record their
plan is divided into an orange zone and a yellow readings immediately but either fabricate them or
zone. attempt to remember them later [27, 28]. This
common response should be acknowledged and
• The orange zone extends from 50% to 59%. PEF reserved for specific situations. It is a recipe
Individuals with asthma are generally required for distrust or dishonesty to suggest use of a PEF
to begin using prednisone at this stage. With when the advice is not going to be followed.
the start of oral corticosteroids, they are Therefore, routine daily monitoring of peak flows
required to contact their doctor. is not advocated for all.
The PEFM is useful for short-term monitoring 10.4.2 Calculating Diurnal

and for managing exacerbations. For the person Variability: Other Methods
with brittle asthma or moderate to severe persis-
tent asthma, it can be used for daily long-term Asthma is characterized by marked variability in
monitoring. For children with mild asthma, PEF airflow. This variability is useful when diagnos-
should be done every 6 months in order to record ing asthma and as a marker in assessing severity.
personal best readings, since these will change
with growth and age. 10.4.2.1 Method 1
The general rule of thumb is to find the per- Diurnal variability is used as an approximate
sonal best every 6 months for children since measure of airway responsiveness [29]. It can be
volumes and flows increase with growth. At calculated as the daily amplitude percent maxi-
the other end of the age spectrum, the personal mum, where the spread between daily readings
best for the older adult should also be done (the amplitude) is expressed as a percent of the
every 6 months since lung function reduces highest personal-best reading.
with age. That is:
Highest PEF Lowest PEF 100

Daily variability %
Highest PEF

The simplest method of calculating variability 440 320 120

is to: 120 / 440 0.27272
0.27 100 27.272%
• Subtract the current reading from the personal-
27% variability
best high reading.
• Divide this number by the highest reading.
decimals ignored
• Multiply by 100.
• Write down the quotient (ignore the decimals). In other words, the 320 low reading is a drop
of 27% from the high of 440 l/m.
The resulting number is the variability for this This method is recommended by the
particular individual, expressed as a percentage. International Consensus Report on Diagnosis
For example, using this method, a person with a and Management of Asthma [30] to provide an
high peak flow reading of 440 who drops to 320 index of airway lability.
will have a variability of 27%:
10.4.2.2 Method 2 variability include the amplitude percent

Other formulae used for calculating diurnal mean.
Highest PEF Lowest PEF

Diurnal variability %

Highest PEF Lowest PEF / 2
This is a more awkward calculation, and the 10.4.3 New Personal Best Readings
daily variations do not depend on a single best
high but on the high for the day. However, the The PEF tables are merely guidelines for those
reading can be affected by both time of day at with asthma who have never used a peak flow
which the peak flow readings were taken, the meter. However, for those who regularly use one,
time of waking, and the residual effects of the they can and will consistently start to blow above
recent use of a beta-agonist [31, 32]. their 100% mark (above the established personal
With this formula and the same individual best). This can happen for a number of reasons.
who has a high of 440 but drops to 320 on the
same day, the diurnal variability will be: • Their technique may have improved, so that
the readings are now higher.
440 320 100 12, 000 • They may have responded so well to medica-

440 320 / 2 380 tion that the personal best is now higher than it
31.58% was before.
31% • Younger persons will have grown taller.
Growth spurts are a normal feature of puberty
that can play havoc with carefully developed
This calculation is used in epidemiological personal best readings.
studies and as an outcome measure in clinical • They may have damaged the peak flow meter
trials. or may have changed meters.
• They may have learned to “cheat” [34]. For
10.4.2.3 Method 3 example, spitting in the meter will produce an
The third option is to express the lowest PEF as a impressive high value.
percent of the personal best which, for the same
individual, would be: With the exception of cases where new high
PEFs are caused by defective or damaged meters,
320 100
72% new (and higher) personal best reading for these
40 individuals must be obtained regularly. Those
who switch brands will also see differences in
which means that the person is at 72% of his best their flow rates, and this can make a difference.
peak flow reading, and thus, the actual variability Many peak flow meters do not meet the NAEPP
would be 100–72 = 28%. This calculation is often recommendations for accuracy, variability, and
used in asthma action plans. reproducibility [35].
A variation of the third option would be to New personal best readings have to be taken
divide 440 by 320 and ignore the numeral again when a person changes or obtains a new
before the decimal. Here, 440/320 = 1.28. The peak flow meter. For children, it is suggested that
two digits after the decimal give the variability the best peak flow readings be established twice a
as 28%. year. In some cases, such as with the older adult,
All these formulae are used, with each serving a personal best reading may actually reduce over
a different purpose. The results cannot be com- a period of time. Here, too, a new (and lower)
pared directly. For the asthma educator, the first personal best reading will have to be calculated.
method, recommended by the International
Consensus Report, is recommended. It should be
noted that a wide diurnal variability is indicative 10.4.4 Checking PEF Technique
of poor asthma control [30, 31, 33] and it is the
peak flow variation over a period of time that pro- People forget or get careless. As with most
vides useful information about the individual’s devices, the technique that individuals initially
asthma. learn will be forgotten with time. Hence, it is
essential that they demonstrate (and thus relearn) The diary can also be used to determine
their technique at each clinic visit. Errors in using whether removal of a suspected trigger has actu-
this device have been found at most steps in the ally caused an improvement in health or when
maneuver. Failures include not inhaling fully, a exposure has caused a drop in PEFs. It can also
reduced effort on exhalation, use of tongue, and a help them reduce the delay in seeking medical
reduced number of attempts [36]. assistance.
The educator has to be aware of the methods While the first few points are obvious, the last
that are unconsciously used, which result in a point (communication with the healthcare pro-
decrease or increase in their peak flow readings. vider) may require explanation. The healthcare
Some individuals will spit and increase their provider who reviews a PEF graph can see,
PEF. Others may puff their cheeks and lower immediately, how the person is doing and where
their PEF. Some will place the mouthpiece and when problems began to arise.
against their teeth, and this too will result in read- Further, the information provided can help
ings that are lower than expected. determine whether hospitalization is required.
The PEFM does not measure how long a per- For a person with asthma recently released from
son can blow but rather how hard and fast air is hospital, the PEF can indicate the risk of relapse
expelled. This may cause confusion with those [15].
who are familiar with spirometry, where the vol- The diary is thus very useful in a variety of
ume is measured and an attempt must be made to situations:
empty the lungs. For these individuals, the read-
ings may be inaccurate, and the values obtained • When the AAP needs to be changed or
should be accepted with caution. adjusted
Another error that can be made with the peak • When the person has to seek emergency help
flow meter is to not reset the pointer to zero over the weekend
before each attempt. Some individuals, in order • When the person is away from home and has
to cheat and improve their readings, will hold the to visit a new healthcare provider rather than
meter in such a way that they can flick the pointer his regular healthcare provider
with a finger to move it higher. Further, they may
not do the required number of readings, and the For the person with mild asthma, PEF can be
timing of the recordings may not truly measure discontinued after a few months after an optimal
the daily variation [37]. maintenance program has been formulated.
Further monitoring may be required for acute
exacerbations and to monitor changes in therapy.
10.4.5 The Peak Flow Diary Peak flow monitoring should be targeted to high-
risk individuals with labile asthma and to those
For the person with asthma or their caregiver, the who have a poor perception of airflow limitations
peak flow diary provides: [21].
In conclusion, the peak flow diary requires
• A baseline that helps determine treatment definite commitment by the individual with
• A check on response to treatment asthma to use maximum effort in taking a read-
• Early warning of an attack ing, to record readings on a daily basis, to moni-
• An indicator of the severity of an episode tor PEF daily, and to regularly clean the device to
• Identification of triggers avoid fungal contamination—all of which are
• A means of correlating symptoms with particularly difficult to do when the asthma is
deterioration under control. Discrepant, missed, and fabricated
• An objective measurement of lung function entries can be expected over a period of time.
• An essential tool in communicating with the Hyland [38] showed that one in five entries may
healthcare provider be inaccurate. Other researchers have found
invented entries in about 50% of children’s peak of an impending asthma attack. By the time fre-
flow diaries [39]. Even with electronic peak flow quent doses of relieving medication are required,
meters, users’ claims did not match the data the deterioration is well established. Parents
stored in the devices, and the usage dropped con- should be advised to watch for changes in their
siderably over the 6-month trial with one in four children’s behavior as a warning sign of
users taking a reading once a day and one in three deteriorating asthma, such as a child who wants
taking a reading once a week [39, 40]. However, to sit instead of play or one who becomes very
in general, diaries that are time limited are usefulquiet.
for all individuals to establish a personal best Parents find the asthma peak flow diary help-
reading upon which a treatment program can be ful in noticing deterioration as it occurs and
based. also in judging the response to a bronchodila-
tor. It is seen as extremely helpful in recogniz-
ing severe attacks, particularly when children
10.4.6 Observing Symptoms are asymptomatic or have cough as the only
and Using the Diary symptom [44].
The peak flow meter alone is not sufficient
Individuals with asthma should be encouraged for self-management [43, 45, 46]. However,
not to rely solely on the peak flow diary. PEF is when its readings are combined with education,
not sensitive enough to be used by persons with symptom evaluation, regular consultations,
mild asthma but does provide information for reviews, and appropriate medication, a much
those with severe asthma when combined with better picture will emerge of the asthma that can
a symptom and bronchodilator use diary [6, 41, help them initiate the necessary actions to con-
42]. While the peak flow meter is useful, it trol their asthma [46–49]. Education is the
becomes much more effective when the infor- essential component in every approach to self-
mation it provides is correlated with the per- management [4].
son’s symptoms to get an accurate picture of Once they learn to look at the whole picture as
their health. Symptom records [43] should described above, they will easily be able to take
include: the initiative in treating their asthma proactively
and aggressively rather than after the fact [50].
• Nocturnal awakenings This is particularly true in parents of children
• Use of bronchodilators (very important in with asthma and those individuals whose percep-
identifying acute deterioration) tion of airway obstruction is poor [51].
• Improvement in symptoms after use of a bron- While peak flow meters are recommended,
chodilator in the morning they are only useful if the user is serious about
• Duration of effectiveness of the bronchodila- keeping the asthma under control by monitoring
tor, especially when the duration was less than the readings; otherwise, they become one more
4 hours thing to “use” and then put away.
• Lack of attendance at school or work due to Individuals who should regularly use a peak
asthma (very important in identifying long- flow meter include those with:
term control)
• Brittle asthma (those who have severe exacer-
To this end, all individuals with asthma should bations with little warning)
be encouraged to record symptoms and to learn, • Limited or poor access to medical care due
and become aware of, their body’s signals and to location and distance from a medical
warning signs. Too often, they are unaware that facility
scratchy throats, restlessness and/or fatigue, • Diurnal variation in PEF that exceeds 20%
interrupted sleep at night, cough, wheeze, and an • A history of unsatisfactory response to
inability to do normal activities may all be signs treatment
given to the person and the other is kept at the

Case Study office.
Action plans are based either on symptoms
Bill Brown, 186 cm (6 feet 2 inches) tall
alone (including use of bronchodilators) or a
and 28 years old, was diagnosed with
combination of symptoms and peak flow read-
asthma at age 10. He notices that he is hav-
ings. Their intent is to provide the person with
ing more and more difficulty participating
clear written instructions as to what they should
in sports and often has to take time out dur-
do and when, thereby relieving them of the need
ing a game because he is short of breath.
to remember what the healthcare provider
He says his asthma medication is not as
ordered, particularly at a time when the asthma is
effective as before. Currently, he is on
worsening.
Flovent 100 mcg, two inhalations bid, and
AAPs are easy to understand, but new users
on albuterol prn. His peak flow at your
will need to be shown how to use them, espe-
office is 490 l/min.
cially during the first few exacerbations.
The peak flow reading is low: for his age
Familiarity will breed self-confidence and their
and height, he should be about 650 l/min.
self-confidence will increase each time the edu-
The PEF of 490 l/min is a 33% drop from
cator modifies the plan to match their unique
normal. It would be better to know his per-
exacerbation patterns. Use of and adherence to
sonal best reading and calculate the vari-
the AAP will come about only with the active
ability from that. However, since the
coaching, encouragement, and support of the
medium dose of inhaled corticosteroid is
asthma educator or some member of the team
insufficient to control his asthma, his
[52, 53].
asthma must be reassessed.
Asthma action plans for a fictitious youth
Ask him questions such as the
named Trevor McIvor are shown in Figs. 10.3,
following:
10.4, 10.5, and 10.6. He has moderate persistent
asthma and is at Step 3—the low end of moderate
• Is he waking at night?
persistent asthma. Figure 10.3 is the original plan
• Has he changed jobs recently? Has his
based on peak flow readings, which he was given
home environment changed?
on his initial visit to a new healthcare provider. If
• What known triggers is he exposed to?
Trevor did not use a peak flow meter, he would
• When and how often does he take
have been given a symptom-based plan
albuterol?
(Fig. 10.4). These initial AAPs prescribed two
• How much albuterol is he currently
MDIs: Flovent MDI (the ICS fluticasone) and
using?
Proventil MDI as a SABA.
• Does he have a new pet?
Seven months later, in May, the original plan
was modified (Fig. 10.5). Increased symptoms
And so on.
required him to be prescribed medications at Step
4, the upper end of moderate persistent asthma.
Because Trevor was familiar with the MDI, his
10.4.7 The Asthma Action Plan healthcare provider retained it but added a LABA,
and this time he was given a new combination of
Symptom scores, beta-agonist use, and peak flow drugs—Advair which contained the original
value can be combined into a single “asthma Flovent (the ICS fluticasone), together with sal-
action plan.” meterol (a LABA). The Proventil was retained as
This AAP is a written plan prepared by the a SABA.
educator or physician. It clearly describes what Today, Trevor’s healthcare provider might
action has to be taken for each level of deteriora- choose an alternate medication based on the most
tion. Two copies are made of the AAP: one is recent guidelines [54], using the SMART
Fig. 10.3 Sample asthma action plan using peak flow zones. (©The Asthma Education Clinic Ltd)
approach (single maintenance and reliever ther- added advantage that he can take it whenever he
apy). This is shown in Fig. 10.6. Here, again, the needs relief from symptoms and up to 12 times a
original MDI has been retained but now dis- day. Because he has formoterol, he no longer
penses Symbicort, a combination of budesonide needs the Proventil. He has just one MDI for all
(ICS) and formoterol. This medication has the purposes.
Fig. 10.4 Sample asthma action plan using symptoms. (©The Asthma Education Clinic Ltd)
In all cases, Trevor is provided with oral corti- uments that fit in a wallet. The latter are easier
costeroids for use in acute situations. to carry around and use and less likely to get
The AAP does not need to be lengthy. lost. They have been tested and found to work
Preprinted forms are available, ranging in size [55].
from legal paper to small credit card-sized doc- The AAP is an excellent teaching tool. It:
Fig. 10.5 Modified asthma action plan using peak flow zones. (©The Asthma Education Clinic Ltd)
• Encourages individuals to ask questions and and user, since they are effectively coauthors
learn about the disease of the plan
• Allows the educator to provide customized • Emphasizes the team approach to
information that is specific to their needs management
• Builds trust and rapport between the educator • Offers them control of the disease by permit-
Fig. 10.6 Alternate modified asthma action plan using peak flow zones. (©The Asthma Education Clinic Ltd)
ting a response that is based on symptoms enhance their self-confidence at the same
and/or PEFs time
• Encourages symptom recognition • Provides a written and therefore reassuring
• Allows them to make personal treatment- reminder of what to do and when, thus encour-
related decisions that are satisfying yet aging self-management
In addition to empowering users, the AAP signs should be identified as often as possible.
develops and encourages trust. It is more than a These include:
document. It is the key to a dynamic process that
encourages collaboration with the educator as • Lack of ability to perform normal exercise
both persons work to adjust and fine-tune its • Disturbed sleep
details. • Increase in use of symptomatic treatment
Having a written action plan that aids self- (bronchodilators)
management has been shown to significantly • Failure of effect of bronchodilator
improve outcomes, regardless of whether the • Change in the peak flow — a fall of greater
AAP is based on symptoms or on peak flows. than 15%, and an increase in diurnal variation
Interestingly, parents prefer the symptom-based
approach for their children [26, 56, 57], while Individuals with asthma need to be made aware
adults will start with symptoms and then use PEF of the warning signs of deterioration in their
to make subsequent adjustments to treatment asthma. Focusing on both symptoms and peak
[58]. flows will help them anticipate an attack. Then, by
The AAP requires regular review and revision taking appropriate action, such as removing them-
after every acute exacerbation. selves from exposure to a trigger and/or intensify-
When combined with education, the AAP has ing their drug regimen, they may slow the
been shown to not only provide a benefit to indi- progression of the attack or even prevent it.
viduals with asthma but also to be cost-effective
in reducing costs related to ED visits and hospi- 10.4.7.2 Other Approaches
talizations for attacks [59]. The personal asthma action plan (AAP) should
be followed during periods of deterioration. But
10.4.7.1 Acute Asthma there are other measures that should be taken
The language used for asthma deterioration by until control is regained. These include:
professionals is evolving. Different terms have
different implicit assumptions. In Chap. 9 the • Modifying and limiting activities that require
preference for the term “asthma attack” by those energy
with asthma was noted. This phrase and other • Arranging the body in a comfortable position
phrases, such as “acute asthma” or “status asth- with the head and shoulders propped upright
maticus,” all suggest that individuals remain in • Periods of rest
good health until an external agent arrives, which • Maintaining hydration by drinking warm fluids
causes a sharp deterioration. In reality, episodes though excessive hydration is not advisable.
of deterioration in asthma are usually much
slower in onset, with severity, at least partly In addition to the above measures, there are
determined by the degree of asthma control when other measures which may help, though supporting
well. Nevertheless, perception of the onset of the evidence is neither always convincing nor consis-
deterioration may be abrupt. tent. The idea of “breathing exercises” may seem
Attacks can often be prevented by appropriate odd to many people, as this is an essential function
avoidance of allergens, avoidance of irritants, and of life and newborns do not need instructions to
regular prophylactic drug use. Even when deteri- breathe! Yet belief in their efficacy is strong. The
oration occurs, it can often be identified early Buteyko (pronounced “boo-tay–ko”) breathing
using symptom scores and peak flows. Once program has advanced the idea that asthma is due
identified, further deterioration can be to chronic underventilation and that by teaching
prevented. individuals with asthma to hyperventilate, the
Using this approach, many asthma attacks can asthma can be controlled [60]. Both these measures
be prevented. While this does not hold true in all include breathing exercises [61], massage therapy,
cases, the fact remains that as many warning and relaxation techniques [62] but do not replace
Belly breathing with pursed lips for Belly breathing with pursed lips for young
teenagers and adults children
Instruct the patient to:

Ensure that the nasal passage and Instruct the PARENT to:
trachea are free of secretions and
congestion. Coughing will help. Sit facing the child and look at the child.
Achieve a comfortable position, Take hold of each of the child’s hands, or
either sitting or in semi-Fowler’s allow the child to rest his hands in the
position in bed. (The head of the bed parent’s hands.
should be at an angle of 45˚or 90˚if
the patient will tolerate it. Raise the While breathing in,
head of the bed or use pillows and the parent slowly lifts his hands (thus lifting
cushions to support the back). Relax the child’s to the level of the child’s
the abdominal muscles. Flex the hips shoulders but not higher) and says:
and place a pillow under the knees.
Inhale deeply through the nose while “Breathe in slowly. Now hold your breath.”
keeping the mouth shut. During
inhalation, the patient should feel the (The parent performs the maneuver with the
diaphragm pushed down while the child. Breath is held for as long as the child can
abdominal wall is pushed outward. manage without difficulty)
Place a hand on the abdomen and feel
the hand rise while inhaling. The parent then says
Take a deep and even inspiration.
Pause. “Now blow out through your lips slowly.”
Purse lips.
Exhale slowly, steadily and quietly The parent repeats this action till the child is
through pursed lips as though calm and relaxed.
blowing.
Use the abdominal muscles during --------------
expiration to remove all air from the
lungs.
Repeat for 10 to 20 minutes. Explain to the parent that
lifting the child’s hands causes the child’s
Explain that: arms and rib cage to lift, making it easier to
exhalation should last two to three inhale
times longer than inhalation. lowering the hands helps exhalation
the technique should be practised on a the child is reassured by the parent’s touch
regular and continual basis and not and by breathing in synchronization.
used only during an asthma
exacerbation.
Fig. 10.8 Belly breathing with pursed lips for young
children. (©The Asthma Education Clinic Ltd)
Fig. 10.7 Belly breathing with pursed lips for teenagers
and adults. (©The Asthma Education Clinic Ltd)
breathing. The purpose of this technique is to help
empty the lungs. The pursed lips technique facilitates
appropriate medication. In one small study involv- exhalation in that it allows the airways to maintain a
ing 32 children, massage therapy reduced anxiety, positive pressure, enabling them to remain open lon-
particularly those aged 4–8, and lowered anxiety ger, for increased exhalation.
among those aged 9–14. Daily massage, done by The combination of these two techniques
the parents at bedtime, seemed to improve both air- serves to reduce anxiety and lessen dyspnea
way caliber and control of asthma [63]. caused by anxiety and, above all, permits them to
Relaxation techniques can be combined with feel as if they have taken control of breathing.
breathing exercises. However, the study mentioned Individuals with asthma may wish to regularly
above did not show improvement with relaxation practice these techniques when they are feeling
therapy. “Belly breathing with pursed lips” (Fig. 10.7) well. Then, when they are ill, they will be able to
is also known as Abdominal or Diaphragmatic employ the technique correctly.
Figure 10.8 provides teaching instructions dysfunction is managed through speech therapy
for children. Here, too, the techniques should and bronchodilator medications have no effect, it
be practiced ahead of time, when the children is important to recognize this diagnosis. Panic
are feeling well. It is often useful for parents to may coexist with asthma. A mild episode of
do these exercises with children at quiet asthma may trigger a panic attack, and the resul-
moments and also when they get too excited. tant severe dyspnea will not respond to asthma
treatment. In many cases, once panic has been
identified as a problem, simple strategies can lead
10.5 S
evere, Acute, and Chronic to its reduction.
Asthma Psychiatric morbidity, particularly anxiety, is
greater in individuals with brittle asthma than in
Individuals with severe asthma, and those labeled those with less severe asthma [65]. Severe asthma
as “brittle” or “unstable,” have characteristics in is frequently accompanied by depression, which
common. They may include any combination of complicates management of the asthma.
the following: Depression serves to worsen asthma and must be
treated [66].
• Previous admissions to an intensive care unit An adequate dose of inhaled corticosteroids is
• Frequent nighttime disturbance essential for individuals with severe asthma.
• Rapid deterioration in asthma Medications such as nedocromil, cromolyn, and
• Marked diurnal variation in peak flow theophylline are sometimes used in persons who
• Frequent use of beta-2-agonists distrust inhaled corticosteroids. Moderately
effective medications have few negative conse-
A general approach to treatment is needed for quences when used in mild asthma but can be
these individuals. The major points to be consid- dangerous when mild asthma is deteriorating or
ered are as follows: severe asthma is present.
An appropriate delivery system must be used,
• Is the diagnosis correct? and the person must understand and be able to
• Has an additional or alternate diagnosis been use it. It is also worthwhile checking that there
made? are no financial barriers preventing adherence
• Has the correct medication in the appropriate with drug therapy. The removal of triggers is one
dose been prescribed? of the most difficult and intractable problems,
• Does the user understand the purpose of the and practical techniques must be discussed at
medication? every visit.
• Is it affordable? In summary, improvement in severe asthma
• Is it actually being taken? [64] can be achieved by rigorously following a
• Have new triggers been identified or intro- number of simple principles and rules [67].
duced into the environment? However, actually following the rules has
• Has environmental advice been taken, and proven to be not as simple. In a review of the
have triggers been removed or decreased? available literature on nonadherence [68],
it was stated that children with no evidence
The primary and alternative diagnoses must of recent improvement had only taken about
be considered whenever asthma is difficult to 50% of prescribed medication. Nonadherence
manage. The alternative diagnoses will vary with was related to characteristics of the disease,
age. In a toddler, there may be a missed inhaled treatment, person, and system of care. It was
foreign body; in an older person, there may be a suggested that special programs for difficult-
coexisting heart disease. In adolescents and to-manage individuals might lead to behavior
young adults, vocal cord dysfunction is com- change, with improvement in outcomes of ill-
monly confused with asthma. Since vocal cord ness and potential cost savings. It is likely that
10.6 Potentially Fatal Asthma 363
the conclusions and suggestions are applicable and those introduced by the healthcare system
to anyone with asthma whatever their age. itself.
Overuse of bronchodilators is an important
marker of severity. Those who use bronchodilators
10.6 Potentially Fatal Asthma frequently are often not taking adequate doses of
preventive medication and are being exposed to
Potentially fatal asthma (PFA) is used to describe known triggers. Some studies claim that bronchodi-
those who are at very high risk of dying from lator overuse is the major cause of death in adoles-
their asthma. Generally, it is not a single factor cents [67]. This belief focuses on a symptom and an
that results in death but a combination of factors. epiphenomenon (additional or secondary occur-
In children, death from asthma is very rare. But rence in the course of a disease), and bronchodilator
when it occurs, identified risk factors [69–75] use, rather than the true underlying causes.
include: Professional help from a psychologist or psy-
chiatrist is required when any of the following
• Family dysfunction indicators is observed:
• Parent/child conflict
• Emotional disturbance • Emotional and psychological stresses of
• Parent/staff (healthcare personnel) conflict puberty
• Depression • Under medicating to avoid side effects
• Disregard or denial of perceived asthma • Failure to comply with treatment in order to
symptoms either assert independence or to obtain peer
• Self-care in hospital that is inappropriate for acceptance
the age of the person • Avoidance of medical personnel in attempts to
• Uncontrolled or poorly controlled asthma be uncooperative
[75–77]
This type of professional help is important,
The last five items pose a high risk of respira- although it is difficult to demonstrate that it actu-
tory failure and death. Healthcare professionals ally prevents death. Any team dealing with severe
must be watchful for sources of anxiety and panic asthma must include a psychosocial professional
in children when they are hospitalized. These may well-informed on issues affecting persons with
include the underlying anxiety of being in a hospi- asthma.
tal, family dysfunction and conflicts, depression,
asthma, side effects of medication, fear of medical
procedures (such as IV needles, oxygen tents, and Points to Ponder
mechanical ventilation procedures), and central
nervous system changes. After discharge, the High-risk factors for potentially fatal
results of anxiety often lead to medical difficulties asthma:
that include attacks, oversedation, and manage-
ment failure [78]. Other risk factors included inap- 1. Depression
propriate self-care, reduction of prednisone by 2. Emotional disturbance
more than 50% while in hospital, increased asthma 3. Disregard of symptoms
symptoms prior to discharge from hospital, and 4. Refusal or fear of medical procedures
disregard of asthma symptoms [79].
As noted, PFA can result from a deadly blend
of mistakes and oversights: those made by the Individuals at risk of death from asthma
individual, those made by healthcare providers, include those who [9, 21, 30, 80–83]:
• Have been recently discharged from hospital • Illiteracy

• Have had recent hospitalization or emergency • Low level of literacy or comprehension
care visit for asthma in the past month • For the older adult, prescriptions for too many
• Have had two or more hospitalizations or medications
emergency visits for asthma in the past year
• Have a past history of sudden severe In these cases, appropriate consultations must
exacerbations be sought prior to modifying the prescribed
• Have received prior intubation for asthma asthma regimen.
• Have a prior admission to ICU for asthma Male gender, a FEV1 <50% of predicted
• Have multiple allergies prior to bronchodilator use, and a lack of con-
• Currently use (or have recently stopped using) trol of asthma were associated with death of
systemic corticosteroids adults with asthma [74]. Among adults, risk
• Are using two or more canisters per month of factors include:
short-acting beta-agonists [84, 85]
• Have difficulty recognizing the severity of • Greater severity of asthma
their asthma • Lack of continuity in medical supervision
• Have difficulty recognizing airflow obstruction • Adverse socioeconomic or psychosocial
• Have a short interval between onset and rec- conditions
ognition of symptoms • Lack of access to appropriate therapy
• Delay in seeking treatment • Lack of asthma management
• Suffer serious psychiatric disease [86] • Nonadherence to treatment
• Suffer severe depression [87]
• Have serious psychosocial problems Inattention to comorbid conditions, lack of
• Have a history of seizures associated with environmental control and a sudden sharp
asthma exacerbations decrease in ICS dosage all play a part in fatal
• Use illicit drugs asthma.
• Have a history of conflict with parents and Individuals at high risk of death from
hospital staff about the medical management asthma require intensive education, close
of the person’s asthma monitoring, and prompt care [30, 90, 91].
• Have low socioeconomic status and reside in They can be helped to achieve a higher quality
an urban area of life and, perhaps at the same time, reduce
• Have comorbidity from COPD or cardiovas- mortality.
cular disease
• Are sensitive to Alternaria [21]
10.7 Application
Four factors can enhance the risk for individu-
als with asthma, regardless of age: depression, 1. Interview three adults with asthma. For each
emotional disturbance, disregard of symptoms, one:
and refusal or fear of medical procedures. In PFA • Devise an asthma action plan.
cases, the problem is often related to nonadher- • Present the plan to them and explain it
ence with a prescribed regimen [88]. This may be completely.
due to a number of reasons such as: • Do a follow-up with each person 2 weeks
later.
• Failure to understand the required therapy • Prepare the following:
• Poor familial support –– A written case history for each person
• Classifiable mental illness such as schizophre- –– Your short- and long-term plan for each
nia, bipolar disorder, severe emotional distur- person
bance, and antisocial personality [89] 2. In Chap. 17 , do case study number 9.
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Adherence
11
Contents
11.1 Overview 370
11.2 Healthcare Providers and Self-Management 371
11.3 Adherence: Common Issues 372
11.3.1 Asthma as a Chronic Condition 373
11.3.2 Medication Regimens 374
11.3.3 Avoidance of Triggers 375
11.3.4 Recognition of Deterioration 375
11.3.5 Reaction to Emergency Situations 375
11.3.6 Impact of Asthma 376
11.3.6.1 Effect on the Individual 377
11.3.6.2 Effect on the Family 378
11.3.7 Coping Strategies 378
11.3.8 Psychosocial Factors 381
11.4 Adherence 385
11.4.1 Definition 385
11.4.2 Physician and Healthcare Provider Adherence to Guidelines 386
11.4.3 Nonadherence 388
11.4.4 Patterns of Nonadherence 389
11.4.5 Identifying Nonadherence 390
11.4.6 The Team Approach 391
11.5 General Approach to Adherence 392
11.5.1 Strategies for Chronic Illness 393
11.5.2 Anticipatory Guidance 394
11.5.2.1 Short-Term Counseling 394
11.5.2.2 Long-Term Counseling for Parents 394
11.5.2.3 Counseling for Adolescents 395
11.5.2.4 Long-Term Counseling for Adults 396
11.5.3 Skills Required by the Educator 397
11.6 Specific Aids to Adherence 398
11.6.1 Self-Management of Asthma 401
11.6.1.1 Attack Management Skills 403
11.6.1.2 Prevention Skills 404
11.6.1.3 Social Skills 404
11.6.2 Health Education 406
370 11 Adherence
11.7 Cultural and Religious Differences 407

11.8 Suggested Reading 414
References 414
Key Points
4. List the psychosocial factors that affect
• Adherence is an essential requirement the course of asthma.
for successful asthma management. 5. Discuss how cultural and religious dif-
–– Healthcare providers must abide by ferences can affect the relationship
the latest guidelines. between the educator and the person
–– Individuals with asthma have to with asthma.
avoid triggers, take medication, and
recognize and respond to situations
while evolving coping strategies to
deal with the impact of asthma. 11.1 Overview
• Nonadherence patterns are identified
and strategies to deal with them are This chapter, entitled “Adherence,” deals with an
outlined. extremely important topic that is not without con-
–– There is variation with age. troversy. In terms of those with asthma, it refers
• Specific aids to adherence are outlined. to the extent to which the asthma-related behav-
–– Education is used in management, ior—taking medication, observing environmen-
prevention, and social skills. tal restrictions, and implementing other lifestyle
–– Anticipatory guidance is also changes—corresponds with the healthcare pro-
considered. fessional’s (HCP) recommendation and results in
• Suggestions for dealing with cultural a significant benefit. Adherence can also be
and religious differences are provided. applied to the behavior of the HCP. Does the
HCP, when caring for a person with asthma, fol-
low the current guidelines? Is the HCP up-to-date
on the available medication and devices and
aware of the developments in education of the
Chapter Objectives person with asthma? There are almost-synonyms
After reading this chapter, you should be for adherence, but they, along with the word
able to: adherence itself, should be further applied to
those with asthma or the HCP with their implica-
1. Discuss the common issues involved in tions and meanings.
asthma-related. Adherence to HCP recommendations by those
2. Identify the different patterns of nonad- with asthma is of course important. But so is the
herence, and list specific aids and strate- life of the person with asthma important.
gies to improve adherence. Adherence to recommendations is never likely to
3. Discuss the three levels of skills that be 100%, even when the one with asthma aims to
individuals with asthma require in order follow every instruction. Sometimes an individ-
to achieve guided self-management of ual dose of preventer medication will be missed;
asthma. sometimes there will be inadvertent exposure to
an environmental trigger. For example, some
11.2 Healthcare Providers and Self-Management 371
individuals may be unavoidably exposed to adherence nor concordance—is perfect in itself.

smoke occasionally at work or may inadvertently This chapter uses the word adherence mainly
visit homes in which there are pets. By contrast, because it is the one most widely used, and the
some individuals with asthma refuse to take regu- most familiar, and one that immediately conjures
lar inhaled corticosteroids, using frequent doses up a mental image of what has to be done. It also
of SABA to the extent that two inhalers are used used the definition shown at the beginning of this
per month. Others will continue to smoke and to chapter.
live in homes with pets. There are stark differ- The educator should note that all these
ences between these patterns of behavior, but in attempts—to find inoffensive, inclusive, gender
reality, there are many gradations. Individuals neutral, and politically correct words—continue
will vary considerably in their general degree of in numerous professions, even as this book is
adherence and also in specific adherence at dif- being written. They will continue, and it is doubt-
ferent times and under differing circumstances. ful whether a clear-cut, completely acceptable set
Ensuring adherence by the individual with of terms will ever emerge. However, while the
asthma is now recognized as an essential part of terminology will change with the passing of time,
any HCP’s responsibility. In the field of medi- the key to a successful educator relationship will
cine, the words compliance, adherence, and con- remain unchanged. The successful educator is,
cordance have all been used, at different times, to and will continue to be, a person who listens to
describe the performance, by the person who is and understands the person’s needs and then
ill, of the treatment regimen developed by the incorporates those needs into a treatment plan
HCP. Similarly, the words patient, client, and that is both realistic (in that it accommodates
consumer are all used to describe the person with their needs) and accepted without reservations by
an ailment who consults a healthcare practitioner. the individual with asthma.
None of these words is fully satisfactory, and
each contains objectionable overtones. For exam-
ple, compliance sounds almost military: the HCP 11.2 Healthcare Providers
issues orders and the hapless individual carries and Self-Management
them out. However, HCPs realize full well that
individuals with asthma must be partners in any Consumers of healthcare have always controlled
treatment plan and that a plan developed by them their own lives. From the time of Hippocrates,
and the person jointly is more likely to be fol- individuals have taken advice that suited them
lowed than the one developed by the HCP alone. and ignored advice that did not. This is a reality,
It is from this realization that the word adher- and given that they know their life much better
ence has come into use. Adherence suggests that than the professionals do, this is not at all
the person willingly follows a treatment plan unreasonable.
without being compelled. However, some per- This conditional acceptance of conventional
sons find the word objectionable, because it too medical advice may not have been very i mportant
implies a certain degree of regimentation, with until recently, since many older remedies were
the individual having to adhere to a treatment not effective. Today, however, there is a wide
plan designed by someone else. range of very effective pharmacological sub-
More recently, the word concordance has stances available to the health professional. These
become fashionable. It means an “agreement, or new remedies have very specific uses, contraindi-
harmony between persons and things.” The word cations, and side effects. They are no longer
suggests a shared decision-making, a partnership “snake oil” remedies but scientific formulations.
between HCP and the individual, but it has its Thus, it is essential that individuals with asthma
problems too: it does not immediately bring to comply with instructions.
mind a medical relationship. In fact, none of the The phrase “comply with instructions” sug-
“compliance” words—neither compliance nor gests a passive consumer who receives advice
372 11 Adherence
regarding usage and then follows that advice Knowledgeable HCPs will be able to deal pos-
carefully. This image is far from reality: consum- itively with knowledgeable individuals. They
ers will still adopt those parts of the treatment will ask them to bring their research material—
they like and passively refuse those parts they do whether articles or website addresses—on the
not like. They will rarely do this by direct con- next visit. This will enable the HCP to review the
frontation with the healthcare provider; rather, materials and, if necessary, caution them to re-
they will follow their own inclinations at home. evaluate suspect or incorrect information.
Many HCP now recognize this reality and will An HCP who gives up control will, paradoxi-
often discuss therapy and options in detail with cally, subsequently have much more influence
the individuals. This enables the person to be over the person. This increase will come about
directly involved in the treatment and provides a because of the positive relationship with the indi-
chance to raise practical objections to specific vidual, who will be much more willing to listen
components of that treatment and an opportunity and to enter into an open dialogue.
to discuss anxieties and worries. Such an
approach is much more likely to lead to overall
adherence with treatment and the recommended 11.3 Adherence: Common Issues
regimen.
In the process, the person becomes well Medications can be effective only if taken. The
informed. Many individuals will use the Internet, overall management will be most effective when
or visit libraries, to gain more information. They there is full adherence by the individual to all the
are then able to take a very active role in the man- details of an appropriate treatment regimen.
agement of the condition. When a good relation- Adherence with treatment is a very important
ship exists between the person and the healthcare issue in asthma.
professional, such a relationship becomes pro- Adherence is a new issue in medical practice
ductive and positive for both of them. and one that has been studied only in the last
Many HCPs, however, are uncertain of the three decades. It has arisen at a time when suc-
value of this trend. They may wish to maintain cessful treatment for many conditions is possible.
the degree of control they believe their predeces- At the same time, some of the successful treat-
sors had (although, historically, this control may ment regimens are complex. Asthma treatments
never really have existed). Others will be embar- fall into this category—effective remedies exist
rassed by an individual who knows more about a for it, but these must be taken in a specific fashion
specific topic than they do. After all, most physi- and in the correct dose.
cians or healthcare providers cover a wide range As far as asthma is concerned, there are many
of healthcare issues in their practice, whereas an reasons why a person with asthma may not fully
individual, using the Internet and other sources, adhere to a complicated regimen. Consider its
will focus on, and learn a great deal about his or following restrictive aspects:
her illness.
Some healthcare providers are distinctly sus- • It is a chronic condition.
picious of self-management solutions and self- • It is an episodic condition with remissions.
knowledge. This suspicion should be • Preventive medications must be taken daily.
acknowledged and its root causes identified, and • Medications are expensive.
productive positive solutions should be formu- • Potentially harmful situations must be
lated. There is evidence, but not absolute proof, avoided.
that a well-educated person with asthma manages • Deterioration must be recognized and treat-
their asthma better than one who is not. Most ment appropriately modified.
individuals, after all, do wish to look after • Emergency action may be needed from time
themselves. to time.
• Social interaction may be limited. tioned more than once. Adults, particularly par-
• There is a major impact on family and job. ents from some low socioeconomic groups have
problems that range from reporting children’s
A survey by Huss and colleagues [1] listed reactions (to treatments) to keeping scheduled
some of the reasons why persons with asthma do appointments and following medication regi-
not adhere to recommendations made by health- mens. The lack of social, structural, and financial
care providers and asthma educators. These can support makes adherence to a medication regi-
be grouped as follows: men a low priority. Financial problems that
inhibit either repeat visits to a clinic or the refill-
• Doubt about the effectiveness of such mea- ing of prescriptions, compounded by poor hous-
sures in relation to outcomes. ing and low social support, constitute major
• Insufficient time to make the suggested barriers to these persons. Lack of education, a
changes and preferences pertaining to house- low level of literacy, and poor cognitive abilities
hold issues or resulting altered lifestyle (e.g., further add to the burden. Lack of a spouse has
they may prefer carpeting; the subfloor may been shown to be a predictor of compliance [4].
be unsuitable if the carpeting is removed; they In the older adult, social isolation, disability,
dislike sleeping on vinyl mattress coverings; multiple concomitant health problems, financial
etc.). considerations, and lack of support can impact
• Support issues—lack of assistance, both man- adherence. However, neither age nor social, cul-
ual and monetary. There may not be the family tural and economic factors (including level of
or spousal support needed to make the neces- education), severity of the condition, or health
sary changes. beliefs are predictors of adherence [4, 5].
• Financial issues—lack of finances for the During a pandemic, such as COVID-19, the
changes and potential costs, as in replacing impact of the social determinants of health has
carpets, etc. become even more obvious than before. Financial
problems are exaggerated, personal access to
Turner and others [2] found that there were no healthcare is more limited, and some harmful
differences in the quality of life between those behaviors continue. In this scenario, the educator
who adhered and those who did not. Adults who will need to design online educational modalities
were older, who were better educated, and who and be innovative in providing support and advo-
had a more stable life were more likely to keep cacy to help those with asthma.
appointments and to report that therapy made
them feel better. Of the 985 adults studied, 50.6%
were adherent and 47.4% were not. Strangely 11.3.1 Asthma as a Chronic
enough 82% of those who were adherent and Condition
67% of the nonadherent claimed their reason for
doing so was because it made them feel better. The issue of asthma as a chronic condition is
Fielding and Duff [3] found that socioeconomic important. “Chronic” implies that both the condi-
factors have a major effect on adherence. These tion and the treatment will continue for a long
social determinants of health have been men- time. For some, the discipline of treatment will
continue for years without a break.
The Robert Wood Johnson Foundation Gallup
Points to Ponder poll found that one in seven Americans faces
Adherence may be defined as the following major activity limitations due to chronic illness.
of healthcare advice in such a way that a It seems that Americans have difficulty in accept-
significant benefit is produced. ing a chronic illness because they tend to believe
in technical solutions, place their faith in science
374 11 Adherence
and technology, and are reluctant to accept limits 11.3.2 Medication Regimens
dictated by illness [6].
Asthma as a chronic condition has its most When medications must be taken regularly, the
serious impact on the individual. Its effects are person with asthma needs to devise a system to
felt biologically, psychologically, and socially. It remember to take them on time. Many find it dif-
produces symptoms that alter behavior [7]. It ficult to remember to take their medications every
affects the internal and external resources of the day, and almost all of them forget some of the
individual and the family. Internal strengths (such time. Thus, in dealing with asthma, it should be
as independence, confidence, assertiveness, and accepted that medications will not be taken all of
problem-solving skills) and the external resources the time, and there is a need to focus on ways to
(that include economic assets and the support of minimize the number of occasions when they are
the peer group, friends, and social contacts) are forgotten. Ill individuals, historically, have not
all impinged and compromised by a chronic con- had much success in adhering to a regular medi-
dition. Its impact should never be cation schedule [10–12].
underestimated. Cost is an important issue with regular medi-
Individuals with asthma are required to do cation. The problem of recurring cost is further
more than merely take medication on a regular worsened by the fact that most of the new and
daily schedule. They are also required to take effective remedies are expensive and may not be
bronchodilators as required, depending on their fully covered by drug plans, even assuming that
symptoms, and even to go so far as to modify the individual has a drug plan. If cost prevents a
their environment. They must recognize when an person from filling a prescription, then the medi-
increase in bronchodilator use might be an omi- cations cannot be taken. There may be more than
nous sign and which environments are particu- one individual in a family with asthma, thus
larly dangerous. Thus, symptom comprehension increasing the total cost. The financial drain can
and evaluation are required together with specific add to the stress of the illness, sharply raise anxi-
modification of their environment and avoidance ety levels, and result in poor or maladaptive func-
of triggers, where feasible. All these are aspects tioning patterns within a family [13].
of the treatment regimen. Modifying and adapt- Because of costs, consumers will seek ways to
ing a medical regimen to symptoms and to a make treatment affordable. Generic medications
varying pattern of asthma demands much effort, are low-cost alternatives to brand-name medica-
knowledge, and constant awareness on the part of tions and will generally be supplied by pharma-
the individual [8]. cies unless the physician or healthcare provider
Chronic illness is itself a stressor [9]. marks the prescription “DAW” or “no substitu-
Denial is not unusual in chronic illnesses, and tion.” This indicates that the medication, whether
most of us can understand why this occurs. It a brand-name or generic drug, must be “dis-
may well be that a degree of denial is healthy pensed as written.”
and is one way to cope with chronic unpleas- The person (or parent) may have some insur-
ant situations. However, the combination of a ance coverage for medication. Insurance plans
condition that goes on for years, along with a vary widely in their details and in the premiums
degree of denial, may mean that regular treat- payable, and few provide complete reimburse-
ment will be followed intermittently rather ment. There may be government-sponsored plans
than continuously. Even when there is no for the poor, the very young, and the older adult.
denial, those with asthma may become too Both private and government-sponsored plans
comfortable with one approach to this condi- may cover only a limited list of medications.
tion. When new—and demonstrably better— The poorer the person, the more important the
treatments become available, there may be a details of the plan. The educator must know its
reluctance to discontinue the old approach and details. Pharmaceutical companies provide some
move on to the new treatment. financial relief in the form of indigent-patient plans.
11.3.3 Avoidance of Triggers can have serious ramifications and even require
that the person give up her or his current occupa-
While a reduction in allergen exposure helps tion and seek employment in another field.
reduce the frequency and severity of the asth-
matic response [14], the ongoing need for people
with asthma to avoid their triggers raises many 11.3.4 Recognition of Deterioration
problems, all of which should be considered. For
example, a person with a major pet allergy will Many individuals with asthma have difficulty
have obvious problems if there is a pet in the recognizing deterioration. Again, this is under-
home. If the pet is removed from the home, then standable, given the chronic nature of the illness.
the pet’s owner will be very upset, whereas if the They will believe that they are progressing satis-
pet stays in the home, the person with asthma factorily, even when the asthma is getting worse.
may not feel fully appreciated in the home, and To some extent, this may be denial; however, per-
physical health will be affected. Even a compro- sons with chronic asthma may not feel as breath-
mise, such as confining animals to one room in less at a given level of airway obstruction as
the house, may not be fully effective. Pet dander persons without. Peak flow readings are a very
will travel throughout the home, even if the pet is helpful measurement for early detection of
confined to one room. Many people regard their deterioration.
pets as full family members and are strongly Some individuals cannot recognize when their
attached to them. In this situation, it can be very asthma is deteriorating—even when the rate of
difficult for them to accept that their “animals” deterioration has increased—and this is one of
are harming them. These issues are even more the factors leading to acute attacks. Chronic
difficult to resolve in the COVID-19 pandemic symptoms cause them to adapt to increased air-
with many families being confined to their way resistance, so that progressive bronchocon-
homes. striction is not clearly sensed [15]. For some
The need to avoid triggers of asthma can also though, the sensation of dyspnea and increase in
limit social interaction. People with asthma may bronchial lability accurately reflect the actual
be unable to visit homes of relatives or friends physical situation in the airway. These individu-
who have pets or who smoke. For adolescents als have fewer emergency medical visits and, in
and adults, social commitments often make the case of children, miss fewer days of school
avoidance of triggers a problem. Meeting at a bar [16]. A significant number of individuals under-
or at a night club where smoking is permitted can estimate the severity of their asthma and are at
cause problems for the person with asthma, who risk for increased illness and death [17].
may be reluctant to give up a social engagement
and miss the fun of being with friends. Perhaps
the current widespread use of online connections 11.3.5 Reaction to Emergency
will continue, at least to some extent, after the Situations
pandemic is over and socialization can continue
without harmful exposures. Deterioration is linked with increasing symp-
Both the school and the workplace present toms. In turn, the severity of symptoms directly
their own problems when it comes to avoidance affects the decision to seek medical help [18].
of triggers, such as perfume and scented prod- Once identified, further deterioration must be
ucts. Many work environments can trigger prevented. The action to be taken may involve
asthma. Occupation-related asthma hazards are visiting or consulting a physician or other health-
also difficult to avoid: consider the baker with care professional, increasing the dose of the long-
asthma who mixes dough daily or the hairdresser term treatment in use, or starting powerful
with asthma who is surrounded by hair spray, medications such as systemic corticosteroids on
dyes, and strong chemicals. Avoidance of triggers their own initiative. For these reasons, it is not
376 11 Adherence
surprising that there is a tendency to delay taking • Results in hospitalization or medical proce-
emergency action. dures that are frightening and threatening to
Many individuals with asthma will delay the person’s sense of control
seeking help in acute asthma. Janson and Becker
[19] listed seven reasons that include: The psychological and social factors resulting
from asthma play an important role in the out-
• Uncertainty as to what needs to be done come. Anxiety and depression [20] are the most
• Avoiding disruption to normal routines common forms of psychological morbidity, and
• Minimization or underestimation of the sever- post-traumatic stress disorder can follow an acute
ity of asthma symptoms exacerbation [7, 21]. Individuals with asthma
• Fear of the side effects of inhaled or oral have more nightmares than those without, though
corticosteroids the frequency declines with age [22].
• Discomfort with ED services based on past Family issues are important whether the per-
experiences son is a child or an adult. Some of the common
• Independence, self-reliance, and determina- issues with adults, at home and in the workplace,
tion to handle the exacerbation without out- have been described in considerable detail by
side help studies on the effect on families where a child has
• Lack of financial resources asthma.
Asthma has a major impact on the entire
When exacerbations occur at night, they tend family, both parents and siblings, even if just
to be even more reluctant to disturb the house- one member has the condition and the severity
hold and seek help. Disruption of daily function- of that impact cannot be overemphasized.
ing and prior unsatisfactory experiences with Constant attention and care may be a cause for
medical care are powerful disincentives that jealousy and friction that will affect the devel-
delay the decision to seek medical aid. opment of the normal emotional relationship
between siblings. If the asthma is severe, the
children without asthma may be neglected both
11.3.6 Impact of Asthma unintentionally and unavoidably, resulting in
jealousy and emotional problems [23]. This
As with any physical illness, asthma has biologi- resentment can worsen if a loved pet has to be
cal, behavioral, and social consequences. Illness removed.
changes a person’s personal focus from the exter- Parents may become overprotective and pre-
nal world to the internal. Less energy is available vent the child from participating in normal activi-
for taking an interest in the environment. ties such as sports, school field trips, and social
Asthma’s unpredictability precludes a sense of events for fear of precipitating an attack [7].
control, and each exacerbation is unnerving and Parents who are totally preoccupied with the
causes an increase in panic and anxiety. asthma and its treatment and who constantly
monitor the child, limiting activities and chores,
Asthma will create a discordant and dysfunctional family.
• Produces fatigue Parents may also become indulgent, failing to
• Imposes physical limitations treat the child with the same degree of discipline
• Restricts physical activity shown toward the other children, making exces-
• Changes the sense of self by attaching the sive allowances for inappropriate behavior,
stigma of illness to an individual allowing the child to do as he wishes, and not set-
• Produces symptoms that change behavior ting limits. This also creates an unsuitable family
either through the condition itself or as a side environment [13, 24]. In both cases, the family’s
effect of the treatment ability to adapt is affected, as is its cohesion [25].
Psychological instability in a family is a strong such as meal preparation and caring for their chil-
indicator of nonadherence [26]. dren [30] In the past, with gender stereotyping,
Asthma also affects the relationship between these tasks were assumed to be the mother’s
the parents. Having a child with a chronic illness alone. Most studies have focused on the mother’s
imposes considerable stress on the relationship role, but the conclusions are likely true for the
between husband and wife. In most cases, the parent with asthma who provides the bulk of
degree of stress directly corresponds to the degree childcare. It must be remembered that when the
of severity of asthma in the child. Families unable parent with asthma is a single parent, and over-
to cope with the psychological and physical stress whelmingly this applies to mothers, there are
of having a child with a chronic illness become additional burdens. This is an indirect cost of
dysfunctional and sometimes break up, imposing asthma.
even greater emotional turmoil on the child with Spouses or partners recently diagnosed with
asthma and greater stress on the single parent asthma are placed in the unenviable position of
(usually the mother) who then has to look after explaining to family members (or significant
the child. partners) asthma, its triggers, and its seeming
unpredictability. Coping difficulties on a personal
11.3.6.1 Effect on the Individual level are increased if it becomes necessary to
Children with asthma are very aware of their request changes in the partner’s behavior. Should
many restrictions and can list the many things the partner or spouse be a smoker, a request not to
that they cannot do. They are also aware of their smoke can add considerable stress to the relation-
symptoms and treatments and the necessity for ship. It may be difficult to achieve a relationship
adaptation [27]. Children aged 6–7 years old see when the potential partner has had a pet for a long
asthma in terms of symptoms and place emphasis time or an acquaintance smokes or wears scented
on the negative feelings associated with asthma. products.
As they enter the early teens, the emphasis moves Teens and young adults find it difficult to
to the restrictions imposed by the condition. explain their need to avoid triggers, particularly if
Reconciliation and acceptance occur only in late the new romantic partner has a pet. Some may go
adolescence. The most alarming aspect of a to great lengths to pretend that they do not have
child’s awareness of asthma lies in the fear of asthma, relying on their bronchodilators for help
death. This fear is far more predominant among until the situation deteriorates. In addition, social
African Americans than Caucasians. They also activity for some teenagers and young adults
perceive their lives as being markedly different revolves around visits to bars and attendance at
and appear to be more adversely affected by events where smoking is permitted. Many mem-
chronic illness than do Caucasians [28, 29]. bers in the social group will smoke. All this
The attitude of schoolmates, teachers, and causes additional stress for young persons with
particularly physical education instructors is asthma.
extremely important for both the emotional and The workplace must also be reviewed.
physical well-being of the child with asthma. Too Chronic asthma may affect a person’s ability to
often, students with asthma are viewed as “lazy, do certain jobs. For some, there may be a prob-
fat, sleepy…” because there is no understanding lem with occupational asthma, but for others the
of their condition, or the nature of asthma, or the impact on a job comes from other reasons,
fact that medication such as corticosteroids can including intermittent absence, the need to have
cause weight gain. dust-free areas, the need for a smoke-free envi-
Parents who have asthma face a different set ronment, to avoid colleagues with perfume, and
of problems. Their children’s promptness and so on. There is a stigma attached to asthma [31],
attendance at school will be affected. Their and it has a negative impact in the workplace in
asthma will interfere with basic parenting tasks that it:
378 11 Adherence
• Hinders employment opportunities diminish career or personal goals. This is not

• Limits career advancement only unfortunate for the one parent affected most
• Can result in discrimination by the employer directly but also can have an adverse effect on the
• Can be a cause for job loss or dismissal financial stability of the whole family. Again, in
• Requires sick leave and time off for medical single-parent families, the consequences of pro-
appointments viding extensive care for a sick child can be
devastating.
The reluctance or inability of some workers to Past experience with the condition as related
take the necessary time off when necessary can by family members or others within the social
lead to inadequate asthma care. circle may determine their ability and willingness
The condition itself has a major impact on all to cope. Taking precedence over all these factors
aspects of daily living [32, 33]. It adversely is the resources that are available to the family.
affects the physical, psychological, and social Initially, there may be strong support, but that
facets of a person’s life. Both the individual and support will dwindle over time. There may be
their family have to maintain a sense of hope and some support during acute episodes but none
some semblance of normalcy while modifying available on a daily basis.
their lifestyle, adjusting their daily routines, and Family resources may be strained as the con-
coping with periodic and unpredictable exacerba- dition progresses. These include the:
tions. Social relationships are often forfeited and
social interaction limited by the asthma [9]. • Financial drain
Social, home, and work/school environments • Cost of the continued illness
may become increasingly stressful and require • Potential loss of income
that they cope with physical discomfort, disabil- • Deterioration in the quality of life of all family
ity, and the stigma of illness [34]. Unceasing self- members
care is often seen as a liability, and many have
difficulty in acquiring knowledge and the appro- Access to the full range of healthcare services
priate level of skill needed in order to maintain is a determining factor in the individual and the
that care. Needless to say, all this has to be done family’s ability to cope.
while the individual is coping with grieving over
losses, resulting from a chronic illness and main-
taining a positive concept of self. 11.3.7 Coping Strategies
11.3.6.2 Effect on the Family Coping is a complex process that begins with

Many factors influence the family’s ability to interpretation and evaluation of a situation and
cope with chronic illness. Primary among them is finally results in an adaptive response that encom-
the asthma itself, its perception by them [35], the passes cognition, emotion, and behavior.
level of disability it produces, the degree of sever- Reaction to the diagnosis of asthma takes one of
ity, the prognosis, and the potential for a return to two directions—the objective route, which evalu-
normalcy or for rehabilitation. The condition ates the health threat and then acts upon it, or the
may pose a threat to the stability of family rela- emotional route, which results in a severe
tionships, status, and goals, both financial and emotional reaction that requires modification or
otherwise [36]. It may impinge on social relation- development of coping mechanisms [35, 37].
ships and affect the functioning of the family. There are three general styles of coping. They:
When one parent is the primary caregiver for the
child with asthma and more particularly carries • Focus on asthma
the sole responsibility, the demands can be • Hide the asthma
exhausting. That parent is very likely to reduce or • Adopt and maintain a restrictive lifestyle
The approach used will depend on the level of ing. Each asthma episode is followed by attempts
fear experienced [38, 39]. A high level of fear to understand the cause. They compare them-
will make them reliant on the HCP, overanxious, selves with others who suffer from the same con-
and more likely to overmedicate. Those with low dition. This comparison can make adjustment
panic levels will ignore or deny the illness, take difficult and heighten fear. Comparison can also
more bronchodilator medications, under-result in maladaptive behaviors, distorted facts,
medicate with controller medications, and as a misinformation, and failure in adherence to the
result have more admissions to hospital. The prescribed regimen [45].
group in between, with a medium level of fear, Individuals with asthma cope in different
will adapt more easily, accept the illness, and ways [46]. Their choice of method often depends
take the medications. on whether they choose to avoid the problem or
While fear affects attitude and influences the handle it to the best of their ability. Neither
person’s intention to act, it has little effect on approach is right or wrong, and the purpose in
actual behavior [40, 41]. Appraisal of a threat can each case is to reduce the level of anxiety. Either
motivate self-protective behavior. Before change can be useful as long as it helps them and their
can take place, the individual will evaluate the family cope. Generally, they practice both meth-
threat, the need for change, the costs involved, ods, selecting either one based on their needs at
and whether they can cope with the necessary the moment. Coping mechanisms are summa-
adjustments. rized in Fig. 11.1.
The coping strategy finally employed will be a Coping techniques often include a desire for
direct function of their knowledge, attitude, and more information. Many individuals feel that
support system and will be chosen based on their: knowing more about the condition will provide a
• Knowledge about asthma, awareness of the

Methods of Coping
level of danger, and perception of its threat to
their well-being Less useful, more likely to harm
• Belief in the efficacy of the treatment and their - denial of disease
degree of optimism that a solution can be - minimization of signs and
symptoms
found
- refusal to participate in treatment
• Schedule and time availability—whether there
- minimization of problems
is sufficient time to think about, understand,
- social isolation
and learn about the condition - excessive dependence on others
• Social support - increased need for sleep
- allocating blame to others
Families play a crucial role in the well-being - deliberate delays in decision making
of a person with asthma. If they see asthma as - setting of unrealistic goals
unpredictable and unmanageable, they may with-
More useful, less likely to harm
draw support from the person, who in turn may - seek information
withdraw from or refuse treatment. Family influ- - express emotions
ences and supportiveness play a major role in the - verbalize concerns
ill person’s health and the degree of adherence - use relaxation exercises
and provide a significant buffer for stress [9, 25, - use stress management techniques
34, 42, 43]. The most important psychological - use problem solving approaches
influences on asthma management in the home is - use positive thinking techniques
the family’s, rather than the individual’s, adjust- - choose activities that divert
ment to the condition [44]. - set goals and strive to achieve them
Part of the adaptive process in adjusting to a
chronic condition is a person’s search for mean- Fig. 11.1 Methods of coping
380 11 Adherence
degree of control. If they know what to expect, Short-term denial allows them and their fami-
then any exacerbation is less likely to alarm. The lies to maintain the illusion of control and may be
sense of control is important whether or not there a precursor to the development of actual ways of
really is control. For example, the use of relax- coping. It is also an adaptive mechanism. The
ation exercises such as belly breathing and “tak- negative effects of denial can include a delay in
ing control of breathing” may or may not be seeking treatment, an increased number of hospi-
effective but may make them feel better. There talizations, isolation, and even increased anxiety
will not be side effects from these techniques, when the individual is no longer able to deny the
provided they are not used as a substitute for condition [47, 48].
environmental control. Others use humor, while Some individuals choose to blame others, to
yet others approach the exacerbation as a prob- avoid making decisions, and to maintain an unre-
lem to be solved. alistic perception of the condition. Some may
Some individuals with asthma and their fami- even go so far as to refuse treatment [49]. Severity
lies set goals and strive to achieve them. A family is a major factor in coping [50]. Those with brit-
whose child is frequently in hospital may choose tle asthma have more difficulty coping. They are
to set a goal of staying out of the hospital for a at risk for greater psychosocial and psychiatric
month. And they may extend the time period as morbidity. Coping is also a function of well-
they work to control the child’s asthma. As is the being. The more severe the attack, the longer the
case with any goal, this one can be helpful—if it healing period. Each increase in the length of an
leads to family support for environmental con- exacerbation leaves the person more fatigued and
trols and adherence with medication—or harmless able and willing to cope in every respect. The
ful, if it causes significant symptoms to be ability with which an individual copes or fails to
ignored. Asthma severity will cause them to keep cope has a major influence on both the course and
extending their goals. Initially, the goal may be outcome of the asthma.
for a night of uninterrupted sleep. A subsequent Both the physician or healthcare provider and
goal may be a reduction in medication. Control the asthma educator play a major role in helping
and self-management cannot be achieved over- them cope with the chronicity of asthma. It is
night but will require a considerable amount of essential that both the HCP and educator recog-
time and practice. With the achievement of each nize the depression, resulting from a feeling of
goal, they will be able to extend their horizons. helplessness and loss of control, that accompa-
However, they will, at some time, brood over nies a chronic illness [34, 51]. They also play an
the condition and its effect on their lives. An edu- important role in the person’s life. They can do
cator may incorrectly view this as a path to much to help by [52]:
depression, since the focus is on what they can no
longer do. However, this is a normal part of the • Explaining the process of care and the ratio-
grieving process. They need to express their feel- nale for different actions
ings, including anger, at a condition that has • Teaching about medications and devices and
robbed them of what they consider a normal life. how to avoid side effects
When acceptance is very difficult, they may • Checking technique, care, cleaning, and main-
choose to deny the condition, to minimize the tenance of devices
signs and symptoms, and to underestimate the • Teaching appropriate environmental control
severity and size of the problem. Some may techniques
indulge in additional hours of sleep as a means of • Helping them develop coping strategies and
avoidance. They may not want to think about the stress management techniques
asthma or consider its implications. They may • Helping them modify their expectations
not yet be ready to face the facts. They may iso- • Encouraging helpful attitudes
late themselves within their family or social • Employing behavioral techniques to teach
circle. self-monitoring skills
• Providing continuity of care, with sufficient In strict medical terms, modern asthma man-
time to develop a positive relationship [53] agement has been very successful, both in using
• Helping build a support network through medications (principally inhaled corticosteroids)
introductions to local support groups and in stressing the importance of environmental
• Providing the support that is instinctively control in combination with allergen avoidance.
looked for when dealing with HCP [54, 55] Treatment has been so successful that many
healthcare professionals have failed to recognize
Failure on the part of the HCP to communi- the need to go beyond the prescription of appro-
cate with the individual, and to provide both priate treatment and to inquire into the overall
information and emotional support, can prevent effect of asthma on the individual and the family.
the person from coping adequately [38]. During The growing literature on adherence is an indica-
assessment, the HCP should also assess the indi- tion that prescribing treatment will not, by itself,
vidual’s ability to cope with the problems that ensure a good result. With asthma, regardless of
accompany asthma. the age of the individual, there is a loss of self-
esteem and a loss of control. The condition
requires constant adjustment of treatment, and
11.3.8 Psychosocial Factors the fear of exacerbation is particularly acute in
the recently diagnosed. It also produces fatigue
“Psychosocial factors” refers to the total effects and a number of physical and social limitations.
of the illness on the individual and the family, It has a far-reaching effect on lifestyle.
including the effect of the social environment and Psychosocial factors have been given empha-
family on the health and illness behavior of a persis in guidelines as being important to success, or
son with asthma. lack of success, in treatment. For example, the
Chronic illness in general generates anxiety, NHLBI Guidelines [52] include the following
depression, and psychological distress. In psychosocial factors as being associated with
asthma, it is not surprising that anxiety and poor outcomes:
depression are the most common form of psy-
chological morbidity. Depression interacts with • Conflict between individuals, family, and
asthma, increasing its severity [21]. The depres- HCP
sion must be treated along with the asthma [56]. • Denial of symptoms
Other psychosocial factors include psychologi- • Depression
cal stress, lack of education, poverty, and family • Behavioral and emotional problems
disturbance. All of these will complicate asthma • Inappropriate asthma self-care
management. Mention has already been made of
the confusion engendered by psychological dys- The International Guidelines [57] also associ-
pnea, anxiety, panic, and vocal cord dysfunction ate low self-esteem, social stigmatization, family
in the diagnosis of asthma and its ongoing care. tension, and difficulty in accepting the asthma as
These conditions can mimic asthma or coexist stress factors that influence its outcome.
with it. Psychological factors may also influence the per-
This section will discuss the general, but very son’s awareness of symptoms, resulting in the
important, psychosocial issues related to asthma, minimization or exaggeration of symptoms, their
rather than the specific psychological conditions intensity, and significance [49].
that can be confused with asthma. There are addi- Psychosocial factors have even been impli-
tional considerations if the person is a child. If cated as important factors in asthma fatalities.
educators are alert to the possibility of psychoso- The British Guidelines [58] list depression, anxi-
cial issues and identify appropriate resources for ety, and denial of the condition as precipitating
them, then the outcome will be considerably factors in asthma deaths. Other factors include
improved. family conflict, life crisis, social isolation, low
382 11 Adherence
socioeconomic status, minority ethnic status, and Poverty affects asthma in many ways. For
illiteracy. example, changes to the home may not be
It is not difficult to understand that the inabil- affordable. The increasing number of individu-
ity to breathe easily will be stressful. Stress in als from low-income families who are diag-
asthma is not confined to exacerbations but can nosed with asthma has led to the postulate that
be ongoing, and the more severe or brittle the these families are at increased risk due to expo-
condition, the greater the stress and psychologi- sure to environmental triggers, high level of dust
cal morbidity [59–69]. Severe stress can also be a mite allergen, cockroaches, molds, and respira-
trigger of an asthma attack [70, 71]. A severe tory viruses, all of which lead to BHR. The
exacerbation can often be followed by post- social determinants of health are relevant to the
traumatic stress disorder [72]. degree of exposure to disease and health and ill-
Psychological stress is also associated with ness behavior [51, 67].
increased susceptibility to various infectious Poverty is another aspect of the social deter-
agents [73–75] which in turn may lead to an minants of health, in terms of access to health-
asthma exacerbation. In the Canadian Prairie care. An adult study [68] in the USA saw
Provinces Asthma Mortality Study, when fatali- significant differences in the treatment of asthma
ties were compared with controls, information in acute- (public) and private-care individuals.
from relatives revealed stress in the lives of those The comparison found that those who relied on
who died of asthma more often than in living the crisis approach to treatment (the acute care
controls [76]. group):
Lack of understanding of the condition com-
pounds other psychosocial problems. Individuals • Were African American.
and their families often have a fragmented knowl- • Were younger
edge of asthma, together with a lack of under- • Were likely single
standing of how to fit the pieces together to obtain • Had fewer years of education
a comprehensive view. They may even appear to • Had younger members in the household
be knowledgeable but, in reality, do not know • Lacked air-conditioning in their homes
how to use their knowledge. • Had air pollution as an asthma trigger
Fears of the condition and exacerbations also • Smoked tobacco
hinder and lower their quality of life. One spe- • Were more reliant on self-care
cific common fear, that of the side effects of med- • Were less aware of asthma management
ications, can be reduced by improving their • Lacked access to resources that stress preven-
understanding of asthma and by clearing up any tive education
confusion that might exist between corticoste-
roids and androgens. They can be reassured that Poverty is also positively correlated with hos-
their fear of abnormal muscle growth, hirsutism, pitalization for asthma [69] and increased levels
and cancer, although very real to them, is a mis- of both anxiety and depression [70]. Low socio-
conception [63]. Fortunately, severe side effects economic status produces stress through a variety
of systemic corticosteroids—such as weight gain of avenues: its inability to finance medical needs,
or acne with resultant change in body image— the perceived or actual threat of neighborhood
are now very uncommon, as usage has declined violence and crime, the lack of affordable housing
dramatically. Other fears, whether or not about and transportation, and the lack of funds for
medication, require the educator to listen care- transportation, medication, and environmental
fully, understand the reason and extent of the control [71].
fears, and explain the known scientific informa- Poverty and its associated stress are found in
tion. Fears are always real, whether or not there is the inner city. Morbidity from asthma is increased
any scientific basis for them, and should never be in inner-city children who are exposed to indoor
made fun of or dismissed lightly. allergens not only at home [77] but also in inner-
city schools—allergens that include cat, rat, and disturbance may affect the sleep of everyone
mouse, dog, dust mites, and cockroaches [72]. in the home, and the effects will be combined
When combined with a chronic illness, low with anxiety. This will affect all family members:
socioeconomic status also has a major impact on siblings may lie awake expecting the child with
the ability of the individual with asthma to remain asthma to have to go to the hospital in a hurry, or
employed. There is a stigma attached to asthma even to die. Sleep deprivation will then affect the
in the adult workplace [31]. A 1996 study [73] daytime performance of everyone.
found those males with chronic illness in manual The mother’s level of education has a major
occupations, as opposed to clerical or manage- impact on the health status of the child with
rial, were less likely to obtain a secure paid asthma [9, 80].
employment than those without a chronic illness. Mothers (and presumably fathers) with intel-
The cumulative result of all these factors is a fur- lectual limitations provide an environment that is
ther decline in the standard of living of the poor lacking in coping and reasoning skills. Further,
with asthma, which in turn has serious health there are poor social skills, inadequately treated
implications. illnesses, problems with hygiene and discipline,
Children with asthma from lower socioeco- and lack of proper nutrition. Problems may be
nomic groups have higher rates of morbidity than further compounded by inability to understand
similar children from higher socioeconomic medical instructions and directions. This may
groups. These children have high levels of stress, result in neglect and lack of adherence.
increased behavioral and adjustment problems, A parent may not understand the requirements
and increased difficulty in the management of of the condition or not perceive the connection
asthma. These children also tend to have two or between exposure to allergens and increased
more caregivers who are also at greater risk of symptoms. In this situation, the parent may be
psychological difficulties due to caring for a child unable to follow the complex regimen required
with chronic illness while struggling with the by asthma, which usually calls for a combination
burden of poverty. While the child’s asthma con- of medication and environmental prevention
tributes to maternal psychological distress, it also techniques.
hinders the caretaker’s ability to cope, to utilize Lack of social support has been linked to
medical care, and to manage the child’s asthma adverse health outcomes [81]. Conversely, a high
[74]. degree of social support, primarily from the fam-
For children, Keller and colleagues [75] have ily, can have a positive effect on the outcomes.
suggested that the lack of third-party insurance This support can come not only from immediate
(private or Medicaid coverage) places them at a family members but also from caregivers, rela-
higher risk for severe asthma. Reimbursement tives, and friends, peer groups, and the many
policies [76], such as those offered by Medicaid social interactions that result from being a mem-
and Medicare, cover acute exacerbations but not ber of society. However, the family is the most
the necessary preventive care. important form of social support. Families can be
All children with asthma show greater func- supportive (or not) to those with asthma, but all
tional impairment and lower self-esteem and chronic illnesses have an impact on all family
score higher for depression [78]. They have more members separate from the impact on the
disturbed nights than children without asthma, individual.
have more psychological problems, and perform Methods of coping chosen by the family will
less well on tests of memory and concentration. affect the health and well-being of the person
In other words, nocturnal disturbance, which is with asthma. Barton and others [48] showed that
the biological consequence of asthma, goes on to interventions designed to help improve coping
affect the person’s mood, behavior, and cognitive strategies of those with asthma and their families
function [79]. When children have problems had the effect of both reducing psychological dis-
sleeping, this affects the entire family. The noise tress and symptoms. That is, coping strategies
384 11 Adherence
influence other psychosocial factors that contrib- of it makes acceptance and management
ute to asthma management. difficult.
As mentioned above, a supportive family can Because the family is the primary social net-
have a positive effect on outcomes. With a non- work, a person with asthma cannot be helped
supportive family, there will be increased stress without first considering every other member of
on the person with asthma, whether adult or a the family and the overall function of the family
child. Family conflict may drive them to either unit. Those who study family structure empha-
helplessness or denial of the condition with size the importance of qualities referred to as
accompanying detrimental results. The emo- adaptability and cohesion.
tional, financial, cognitive, psychological, and Adaptability defines the flexibility or inflexi-
physical reactions of family members to the bility of the behavioral structure within a family.
stress of dealing with a chronic condition such as It can range from the rigid to the chaotic. Within
asthma will alter the dynamics within the family a rigid family structure, the rules of conduct are
and affect the person with asthma [48]. inflexible, discipline is unbending, and there is a
Family interaction is influenced by the devel- strong focus on rules and consequences. The
opment of respiratory symptoms, and this can rigid family is hierarchical and dictatorial. At the
result in a dysfunctional family where: other end of the scale is the chaotic family, where
there are no rules or where rules are not enforced,
• The members are unable to adapt or adjust to discipline is lax, and decisions made are unfo-
the demands of the situation cused and unpredictable. In between lies the bal-
• The cohesiveness of the family unit is weak- anced, adaptable family, where individuals are
ened, resulting in overprotectiveness or allowed to make choices, discipline is flexible,
increased distancing of the ill member [13]. mutual respect is encouraged, rules are clear, and
• The hierarchical organization within the fam- consequences are age-appropriate.
ily is affected by asthma and results in new Cohesion is the “glue” that binds a family. It
roles being assigned that can often change the ranges from the involved to the dissociated and
structure of the family. measures the level of bonding within the family.
• There is delay in seeking help. The involved family does not permit individual
• Help is sought only in acute exacerbations, decisions; emotional bonds are intense, attention
since these visits are covered by insurance. is unvarying and fervent, independence is dis-
• Treatment of asthma on a regular and consis- couraged, and overprotection is the norm. At the
tent basis is avoided [82]. other end of the scale is the dissociated family
with weak emotional bonds that offers little or no
Wheezing may heighten anxiety in all family support and attention, encourages independence,
members. Increased anxiety results in increased and expects self-reliance and decision-making
tension within the family. Anxiety further reduces without family consultation. Between these two
the family’s ability to cope with the situation and extremes is the balanced cohesive family, where
to solve problems. This is inherently hazardous emotional responses are adequate, independence
since anxiety now becomes a risk factor in the is both supported and expected, support is pro-
development of continuous and/or more severe vided, and attention is age-appropriate. Decisions
asthma. are taken in consultation with other family
Recurring episodes require that the family members.
adjust to a new relationship with the person who A full description of issues relating to family
has to periodically relinquish his societal role as functioning is beyond the scope of this book. In
a functioning individual and resume the mantle both cases, the balanced family is the one that is
of illness and its many demands. The family, most able and willing to cope with chronic illness
being the primary social network, needs to be [25, 39, 83]. The importance of the family and its
supportive in accepting and treating the illness structure cannot be underestimated in the man-
[18]. The ill person needs this support, and lack agement of asthma. While the educator can pro-
11.4 Adherence 385
vide general professional support, skilled family move forward. The educator can also help by
therapy by a qualified therapist will be needed identifying agencies or financial resources that
when there are serious problems. families can access or by helping with letter writ-
Ethnicity interacts with other psychosocial ing when dealing with insurance agencies. Such
factors and seems to be associated with increased assistance will always be appreciated. This is not
emergency visits, hospitalization, and deaths “interference” but an appreciation that chronic
from asthma, although this is difficult to untangle conditions may affect a family’s ability to cope
from associated factors such as poverty. In the with ordinary issues. The educator should be
USA, African Americans have consistently careful not to engage in counseling unless spe-
higher death rates, hospitalizations, and emer- cifically trained to do so. Some individuals may
gency room visits than Caucasians. These ethnic need formal psychiatric help. Liaison with the
variations result from a variety of factors that family healthcare provider is important. They
include behavioral, psychosocial, and environ- should know that the asthma educator will only
mental risk factors as well as access to health reveal their confidences to a third party, or even
resources [68, 69, 84, 85]. These variations are to another healthcare professional, only with
another example of the role that social determi- their explicit permission.
nants of health play in health outcomes. Racial
discrimination affects asthma outcomes in minor-
ity groups [86]. Within a Medicaid population 11.4 Adherence
that spanned the states of California,
Massachusetts, and Washington, Latino and 11.4.1 Definition
African American children were less likely to be
prescribed inhaled corticosteroids than white As discussed at the start of this chapter, adher-
children [87]. This has been noted in other ence is the following of healthcare advice in such
countries. a way that a significant benefit is produced.
Studies in London [88, 89] confirmed that This definition deliberately refers to health
individuals from ethnic minority groups, such as advice rather than to a medical recommendation
Afro-Caribbean and Asian Indian, were less because adherence in asthma involves much
likely to be prescribed medications for asthma more than following a prescription for medica-
than white inner-city children. tion given by a physician: it also involves a major
It is important to emphasize that the recogni- degree of environmental intervention and, in
tion of psychosocial issues to obtain or offer spe- addition, a healthy lifestyle [37].
cific help is not an optional extra for persons Adherence and nonadherence thus present as
dealing with asthma. This section has listed some degrees rather than absolute events. Nonadherence
of the complex psychosocial interactions that should not be equated with ignoring some part of
educators may see in asthma. They always have medical advice. Some nonadherence is rational,
an effect on the individual and family beyond the and on some occasions, professionals themselves
measurable physical effects. If there are preexist- create conditions that invite or impose nonadher-
ing problems with poverty or with family func- ence. For example, if inhaled corticosteroids are
tioning or relationships, the problems in coping prescribed but no teaching is given on their use,
with the asthma are compounded. Educators the person cannot possibly correctly comply with
must be sensitive to these issues. the treatment. Again, if the distinction between
Educators can help in various ways. When anabolic and corticosteroids is not clarified, they
exploring psychosocial issues, open-ended ques- may be too frightened to take the medication.
tions are generally best. It is often helpful if the Knowledge of adherence comes from a num-
individual and family talk about their problems. ber of different studies. One group that has been
The listener should avoid interrupting or offering studied extensively is that of individuals who
solutions. It is usually better if they and their died from asthma. Studies of their behavior
families determine for themselves how best to before death have shown that they [90–95]:
386 11 Adherence
• Did not accept the chronicity of asthma In interactions between physicians and indi-
• Refused to take regular medications viduals with asthma, they noted poor two-way
• Continued to expose themselves to triggers communication, incorrect medication prescrip-
• Failed to recognize and take appropriate action tions, misperception of severity of the asthma
when their condition deteriorated attack by HCP, and incomplete or inadequate
instruction. They also cited failure to explain side
Many other studies [96, 97] on adherence effects, failure to track or monitor the individuals,
have been carried out on living individuals, and and failure to observe and analyze medication-
all have confirmed that this is a complicated phe- taking behaviors.
nomenon that may affect anyone, of any age, They identified three major areas of concern.
social class, or gender. There is no easy solution. Firstly, physicians did not follow the guidelines.
High adherence and healthcare seeking support Individuals with asthma were prescribed inhaled
are present when three conditions are met— corticosteroids for the management of acute epi-
asthma severity, high anxiety, and very severe sodes. This is now permitted in limited circum-
symptoms [35]. stances, but not as a general approach. Or, they
Some degree of nonadherence is universal, were prescribed incorrect dosages (which can be
and it is unreasonable to expect a person with life-threatening, as in the use of theophylline).
asthma to adhere all the time, to all the detailed Secondly, inadequate information about the pre-
instructions—which typically cover regular treat- scribed medication was also seen. For instance,
ment, the action plan for deterioration, the avoid- some were given salmeterol and not told that it
ance of triggers, and the use of inhaled should not be used for acute asthma. Two older
corticosteroids. Persons not prone to periodic adults died and the assumption was that age was
exacerbations will not need to use their inhalers the reason for their lack of understanding. Another
regularly. As a result, they may, in times of emer- study found that 20 deaths had occurred because
gency, use their inhalers incorrectly. In fact, even physicians had not emphasized that salmeterol
regular users will tend to develop bad habits that should not be taken in acute asthma. Thirdly, the
affect its correct use [5]. people being treated were required to adhere to
HCPs are also guilty: not all of them comply instructions they had not been taught [5].
with professional recommendations. For this rea- A 1998 survey [98] found discrepancies
son, when there is a problem with adherence, the between the prescribing practices of US physi-
first action should be to review the treatment plan cians and the National Heart Lung Blood Institute
and to confirm that it is appropriate. Patients are (NHLBI) Guidelines. There were inconsistencies
intelligent: on occasion, they may realize that a in:
treatment plan is not fully appropriate, and rather
than discuss it with the HCP, they simply ignore • Diagnostic criteria. About 20% of people with
the advice. It is therefore essential to explore the asthma reported symptoms that would be clas-
reasons for nonadherence. sified as severe persistent asthma according to
the guidelines, with 22% reporting symptoms
that would be classified as moderate persistent
11.4.2 Physician and Healthcare but were not treated appropriately.
Provider Adherence • Use of appropriate medication. One in two
to Guidelines reported limitations on their ability to partici-
pate in sports due to asthma, while 36% said
Creer and Levstek [5] classified the factors relat- that asthma limited normal physical exertion,
ing to medication compliance in people with 31% said asthma limited their lifestyle, and
asthma into four areas—personal variables, inter- 25% said it limited their social activities.
actions between HCPs and individuals (or their Within the previous year, 50% of children
parents), medication characteristics, and the and 25% of adults reported that they missed
nature of asthma. days at school or work because of asthma.
11.4 Adherence 387
• Use of medication plans. One in every two Hanania and colleagues [100] surveyed medi-
persons with asthma felt that exacerbations cal personnel and assessed their knowledge and
(attack and symptoms) could be treated but ability to use an MDI, an MDI and holding cham-
that asthma itself could not be controlled. ber, and a DPI. They concluded that many lacked
• Education and follow-up. Sixty-one percent of rudimentary skills in these devices since few
those with moderate persistent asthma and receive formal training in their use. Respiratory
31% with severe persistent asthma felt that therapists scored highest in both knowledge and
their asthma was under control, while 71% of demonstration of technique for all three devices
them felt that there was a need for more edu- with scores of 100% for MDI, 100% for MDI and
cation on asthma. holding chamber, and 40% for DPI. Registered
nurses scored 83%, 87%, and 0% respectively,
In management, symptom control, limitation while physicians came in at 53%, 43%, and 13%
of activity, and use of inhaled corticosteroids, respectively.
both individuals with asthma and physicians fell Guidry [101] checked the use of an MDI with
far short of the recommendations in the NHLBI medical personnel in a large teaching hospital.
Guidelines. Similar results were obtained, with respiratory
The Asthma in America survey [98] found that therapists scoring 93%. However, physicians
even though 70% of physicians or healthcare pro- (Faculty of Medicine members and Internal
viders claimed they prepare an action plan for all Medicine residents) rated 65% and nurses 57%,
or most or some of the individuals they treat, only while non-pulmonary personnel scored 50%.
27% of those under their care stated that they were Most of the participants followed the package
provided with such a plan. The same percentage of insert information and were able to correctly per-
healthcare providers said they used spirometry to form 3 out of the 11 correct steps in the use of an
monitor lung function on an ongoing basis, yet MDI. It should be noted that instruction in the
only 35% of those being treated reported having a proper use of an MDI requires between 10 and
pulmonary function test within the previous year. 28 minutes and instruction must be repeated reg-
While most healthcare providers (92%) felt that ularly for persons with asthma to maintain and
inhaled corticosteroids were essential for long- improve their technique [101].
term management, only 15% of the individuals An interactive seminar involving 74 general
with asthma had taken these anti-inflammatory practice pediatricians was conducted by Clark
medications within the previous 4 weeks. and others [102]. It emphasized teaching and
By 2018, nothing much had changed. On communication behaviors. Data was collected
adherence to the guidelines with respect to from all being treated so that the professionals’
asthma control, environmental control, educa- reports could be corroborated. A review of both
tion, and pharmacologic therapy, 1412 primary physician and behavior found that the seminar
care and 233 asthma specialists were surveyed had a significant impact on the prescribing and
[99]. It found that adherence was low among both communication behavior of the physicians and a
groups, though the specialists tended to do reduction in healthcare utilization by those
slightly better. A comparison between the spe- under their care. Of considerable interest was
cialists and the primary care physicians revealed the fact that, after the seminar, physicians spent
the information in Table 11.1. less time with each person but were more effec-
tive. They prescribed more inhaled anti-
inflammatory medications, addressed fears
Table 11.1 Adherence by HCP to published guidelines
about new medications, reviewed and provided
Procedure Specialist Provider
written instructions for medication use, and also
Spirometry testing 45% 11%
Written AAPs 31% 16%
provided written AAPs. Individuals, too, bene-
Home PEF monitoring 13% 11% fited with fewer scheduled visits, fewer follow-
Repeated assessment of 40% 17% up visits, reduced number of both ED visits and
Inhaler technique hospitalizations.
388 11 Adherence
Other factors that affect adherence include ture, adherence is associated even with passive
both the healthcare system and the physician. and subservient behavior.
The former may: It may be more realistic to accept the reality
of nonadherence and focus on how to reduce it,
• Limit time for office visits for physicians to rather than to naively assume that absolute
assess and provide individual counseling adherence is achievable. Implicit here is the
• Limit access to a family physician shift from passive subservient behavior to a
• Have a high practice load relationship between both parties that is positive
• Have different physicians treating the same and equal. The goals and details of treatment
person over time [103] need to be discussed by everyone involved [102,
• Fail to use appropriate health information 105, 106], all of whom comprise the asthma
technology. team.
Nonadherence can be the result of miscom-
It also includes poor communication between munication or lack of communication between
specialists, hospitals, and primary physicians. physician and the person being treated. It can
The physician may: also be connected to the person’s concerns as
well as the complexity of the prescribed regimen.
• Prescribe complex medication regimens Unresolved concerns over the asthma, the medi-
• Have poor communication skills cation—its cost and side effects—the necessity
• Fail to provide information about side effects for the medication, the immediacy of the its
• Disregard the price of medications effectiveness, and the degree of acceptance of the
• Fail to provide education diagnosis, all contribute to nonadherence, as do
• Fail to explain the benefits of treatment and doubts about the efficacy of the prescribed ther-
the risk of nontreatment apy, improper use of inhaler devices, and lack of
• Provide inadequate counseling understanding of the required duration of therapy.
• Teach incorrect device usage [104] Other reasons or factors for nonadherence include
[104, 107–109]:
Thus, failure to adhere to prescribed medical
regimens lies as much with the physician and Lack of belief in the medications
HCP as it does with the person being treated [5]. Fear of medication and side effects
The asthma educator has the added responsibility Poor understanding of the condition
to ensure that the individual has the correct pre- Transportation problems
scription, knows the purpose of the medications Lack of understanding of instructions
and how to use them, and has a written AAP to Poor quality of life
follow when the asthma deteriorates. Low level of literacy
It is only after the HCPs (and educators) have Comorbidities
correctly done their jobs that they expect the indi- Lifestyle
viduals with asthma to follow the required medi- Social factors
cal regimen. Inadequate support systems
Decreased mental or physical faculties
(including forgetfulness, loss of hearing, and
11.4.3 Nonadherence poor eyesight)
Some HCP impose a judgmental approach on

nonadherence. This manifests itself in the harsh Points to Ponder
language used in the literature, which includes Knowledge by itself is not a solution to
terms such as deviant, incompetent, nonrational, noncompliant behavior.
defiant, and unrealistic. In some medical litera-
11.4 Adherence 389
Some degree of nonadherence is universal pharmacy and have the prescription filled. They
with estimates ranging from 10% to 46%. A full may be accustomed to physicians who give them
50% of people who claim to take their medica- medications from a dispensary that is part of the
tions as prescribed tend to overreport it [26, 110, physician’s office.
111] and, on average, only take about half of Very often, people stop taking medication for
what was prescribed [103, 112, 113]. Studies the same reason that they stop taking antibiotics
have not found obvious predictors, despite con- instead of staying the course. They start to feel
sidering age and gender, psychological problems, well and decide that they do not need more medi-
whether parent or treating one’s self, the presence cation. In some cases, this reason may be com-
of family support or lack thereof, and the health- pounded by financial concerns: by stopping early,
care system. they will have supplies of the medication on hand
Any person of any age may be adherent to to self-medicate the next time they fall ill.
treatment—or nonadherent. Nonadherence has Nonadherence may be due to forgetfulness,
been linked with childhood asthma deaths, par- loss of interest, lack of familiarity with the regi-
ticularly in children from dysfunctional families. men, lack of awareness of symptoms, unclear
Knowledge by itself is not a solution to nonad- instructions, and inadequate counseling by the
herent behavior. Many healthcare professionals HCP.
are notorious for their nonadherence when deal- Patterns of nonadherence include:
ing with their personal health problems.
Nonadherence results in poor control of the • Under-use
asthma and can be mistaken for refractory illness, • Overuse
leading to inappropriately high doses of medica- • Random use
tion, unnecessary additions or changes to therapy, • Refusal to change
and increased healthcare costs. It increases the
risk of hospitalization, poor quality of life, loss of Under-use and nonadherence are often con-
productivity, and mortality. sidered synonymous. Under-use occurs when a
prescription is given—for example, for an inhaled
corticosteroid twice daily at a particular dose—
11.4.4 Patterns of Nonadherence and many doses are omitted, perhaps half or less
than half the prescribed number being taken.
The National Council on Patient Information and Some individuals may only miss very occasional
Education (NCPIE) listed the five most common doses, and this will have minimal impact on the
forms of nonadherence as [55]: treatment. Under-use is associated with any com-
bination of the following:
• Not having the prescription filled
• Taking an incorrect dose • A lack of teaching about the medication, or
• Taking medication at the wrong time about device usage
• Forgetting to take one or more doses • Lack of ability to pay
• Stopping the medication too soon, prior to its • Poor understanding on how the drug should be
reaching maximum effectiveness used
• Lack of understanding of the time required for
Reasons for not filling a prescription may be the medication to become effective
financial or even cultural. Immigrants from some
countries may not be familiar with the concept of If, for instance, individuals expect instant ben-
a prescription and may merely regard it as a piece efit from an inhaled corticosteroid and do not see
of paper on which the physician wrote the name an immediate improvement, they may choose to
of the medication. They may not understand that discontinue the use of the prescribed medication
they are required to take the piece of paper to a in the firm belief that it does not work for them.
390 11 Adherence
Again, if the difference between controller and 11.4.5 Identifying Nonadherence

reliever medication is not explained, lack of
instant relief from the controllers may be the rea- Recognizing and accepting the reality of nonad-
son for discontinuance. herence can be difficult. Healthcare profession-
Overuse of asthma medications is probably a als should regard a poor response to treatment as
more common problem than under-use [11] and nonadherence until proven otherwise. Questions
is a very significant part of nonadherence. There about adherence should be incorporated into the
has been much emphasis recently on the overuse routine visit to a physician or healthcare pro-
of beta-2 agonists (the common bronchodilators). vider and nonthreatening questions asked to that
A number of research studies have demonstrated effect.
that overuse of bronchodilators is associated with Other ways [113, 114] of identifying nonadher-
both an increased risk of dying and an increase in ence are more difficult, although more specific.
asthma severity. This relationship is still not fully For example, it is possible to use metered dose
understood. Those individuals who want symp- inhalers with a chronolog (an electronic device
tomatic relief will overuse bronchodilators, which counts the number of doses taken) or to
avoiding regular use of inhaled corticosteroids. count capsules when treatment is by mouth or to
They may also avoid environmental change. ask the pharmacist how often prescriptions are
Random use of medications may be as com- filled. Biochemical investigations can measure
mon as over- or under-use. This situation is a medications in the urine or blood, but these are
challenge for the healthcare professional, as it is used in research, rather than in everyday prac-
difficult to help the individual deal rationally tice. A review of the response to treatment is by
with the problem. Individuals may comply with far the most useful way to monitor nonadher-
the advice sometimes or ignore it at other times; ence. When appropriate treatment has been pre-
they may not take medications for quite long scribed and the response is poor, the most likely
periods and then take them very carefully and reason is that treatment is not being followed.
obsessively for some weeks. Medication costs and side effects, the complex-
Refusal to change is important. People with ity of the prescribed regimen, skill requirements,
asthma must change their treatment when there is frequent dosing requirements, long-term treat-
a change in their condition. Studies of those ment, and delayed consequences to cessation of
admitted to hospital, or of individuals, who have treatment are some of the factors involved in
died from asthma, indicate that their refusal to nonadherence.
change treatment was a major factor behind their
condition. While the phrase “refusal to change”
has been used, it is understood that there is more Points to Ponder
than refusal involved. For example, there may be: When appropriate treatment is prescribed
and the response is poor, the most likely
• Denial reason is that the treatment is not being fol-
• Rational and irrational fears of side effects lowed for a variety of reasons.
• Lack of sensation of dyspnea and thus lack of
recognition of deterioration
• Problems within the family
There are often clues in conversation, and it
Asthma attacks occur from time to time, no can be helpful if, when dealing with a child, the
matter how good the management, and it is there- child and parent are spoken to separately [115].
fore important that individuals know when to Advice regarding pets and smoking is commonly
adjust their response. This is a critical factor in not followed, and again specific questions may
self-management. need to be asked. Some questions are very sim-
11.4 Adherence 391
ple—for example, one might say, “Most of us for- do not wish to consent, their wishes must be
get to take our medications some of the time, and respected.
probably you are like the rest of us.” This type of
wording gives the individual permission to admit
Case Study
to nonadherence. This question can be varied con-
Helen Aitch has come to see you and
siderably, but a version should be used at every
admits that she is having a hard time con-
contact with an individual who has asthma.
trolling her asthma. She is 67 years old and
has followed her physicians’ orders to the
letter. He has told her that every time her
11.4.6 The Team Approach
peak flow readings drop below 150 l/min,
she is to take 10 mg/day of prednisone. She
Three documents:
does and has noticed that for the last
4 weeks, she has been on and off predni-
• Guidelines for the Diagnosis and Management
sone. Further questioning reveals that she
of Asthma [52]
takes the prednisone for 2 or 3 days and
• The recently released Focused Updates [116]
stops as soon as her peak flows go above
• International Consensus Report on Diagnosis
150 l/min. At that time, she discontinues
and Treatment of Asthma [57]
the prednisone and notices that within
2 days her peak flows fall below 150 l/min.
all stress the role of the physician and the health-
She does not know what to do. How will
care professional in assessing the perceptions of
you help her?
the person with asthma, with repeated emphasis
Explain to her that her physician pre-
on the need for a three-way partnership that will
scribed the prednisone because of the
improve both adherence and the outcome of the
inflammation in her airways. He wanted
condition. It is also a stated need for parents
her to take it until such time as her peak
whose children have asthma [114].
flows were normal (predicted values would
The documents emphasize education not only
be around 340 l/min for someone her age).
by the principal clinician but also by other mem-
She should not discontinue the prednisone
bers of the healthcare team [117] and that ongo-
as soon as her peak flows reach 150 l/min.
ing assessment of the individual’s needs is a
She needs some help understanding what is
shared and joint responsibility [118].
happening within her lungs and how to
A good relationship between the physician,
manage her asthma. Check her asthma
the educator, and the pharmacist is important,
action plan (if she has one) and explain it to
and each should be aware of how many prescrip-
her. If she does not have a plan, prepare one
tions are filled. The individual should also be
for her.
made aware that this information is being shared
between team members, and that this will result
in better care. For example, if one or two bron-
chodilator inhalers are used per month and a pre- While educators must carefully think about
scribed inhaled corticosteroid has never been how they will approach the issue of adherence,
purchased, there is clearly a significant degree of the approach should nonetheless be positive.
nonadherence which can be discussed with the Fear is not an effective way to ensure adher-
family. The asthma educator should inform them ence, even though many professionals use it, as
that in order to provide the very best help, the it is the easiest and most tempting tool at hand
educator should talk to the physician and phar- [40]. They may tell the person that death is a
macist, but this will be done only if they consent. likely consequence or that the individual may
If they are uncomfortable with this approach and soon be in an intensive care unit or may have
392 11 Adherence
permanent lung disease. While it might seem 11.5 General Approach

logical that passing this knowledge on to them to Adherence
might lead to adherence with treatment, studies
have in fact shown that this does not work. The World Health Organization quoted Haynes
Individuals with the highest degree of nonad- et al. stating that “increasing the effectiveness of
herence are least likely to change their behavior adherence interventions may have a greater
because of fear. impact on the health of the population than any
Educators should also understand that knowl- improvement in specific medical treatments.”
edge alone will not improve adherence [119]. Before individuals will adhere to a treatment
Some healthcare professionals believe that if per- or management regimen, they must recognize its
sons with asthma know enough about their benefits. Adherence occurs only when they
asthma, then adherence will follow. This is not observe benefits to others or to themselves. They
true: it is quite possible that a well-informed per- need to convince themselves of these benefits
son will remain nonadherent. before they will act. If a person is told by an
Psychological factors play a major role in the asthma educator how beneficial certain actions or
management of asthma. Hence, individual- behaviors will be, they may be willing to try
centered interventions that focus on perceived them, but adherence will only result when they
control will help improve asthma outcomes. A experience the benefits and are convinced that a
positive approach by the educator on the issue of certain course of action has tangible personal
adherence will combine both the knowledge of benefits [4].
the person’s family and an understanding of their Benefits motivate people. They may be a sav-
attitudes to health and illness while being sensi- ing in either time or money; a decrease in work-
tive to cultural, religious, and language differ- load, anxiety, depression, or uncertainty; or an
ences. The NHLBI Guidelines [52, 116] increase in good health, well-being, and sense of
underscore the importance of each team member control. Each person must feel the need to adhere,
for: and the recognition must come from within: it
cannot be imposed by the HCP. They themselves
• Providing education, reinforcement, and will determine what is beneficial to them and act
support accordingly.
• Encouraging adherence through open The conditions [120] needed to bring about
communication this “change of heart” are as follows:
• Individualizing, reviewing, and adjusting 1. The educator must have good interpersonal
plans as required skills and a good working relationship with the
• Emphasizing joint treatment goals and person. Good interpersonal and presentation
outcomes skills on the part of the educator will certainly not
• Encouraging self-efficacy and family ensure adherence. However, educators with poor
involvement interpersonal skills, or who interact poorly with
the family, will almost certainly find that their
Each team member should reinforce and advice is not followed. Good relationships are
expand on what has been taught during every vitally important.
office visit, telephone call, and educational ses- 2. The person with asthma must view the edu-
sion. Communication and coordination between cator and healthcare professionals as consul-
members are important together with documenta- tants to the family. As important as good
tion of all pertinent details (such as individual interpersonal skills is the perceived change in
concerns, beliefs, actions, educational objectives, role for physicians and healthcare professionals,
and asthma plan). wherein they act as consultants and negotiators
rather than disciplinarians. By doing so, they 11.5.1 Strategies for Chronic Illness
implicitly acknowledge that individuals are
responsible for their own health and thereby Knowing the strains and stresses that lie in
empower them.This change in professional atti- wait for individuals with chronic illness, edu-
tude has come about because of the realization cators need to provide teaching in a number of
that individuals make treatment and lifestyle areas: social, management and prevention
decisions based on their perception of what skills, as well as counseling for the social,
works and will only carry out treatment at home emotional, and physical limitations imposed
of that which they approve. This change itself is by the condition.
potentially the most significant motivator for At the first meeting, the teaching time avail-
adherence. able may be short. The educator should hence
3. The educator and healthcare professionals first address immediate anxieties and then pro-
should adopt a stance of negotiation. Both the ceed to device teaching. The goal should be to
educator and the healthcare professionals must leave them with a sense of accomplishment, of
accept the fact that individuals are responsible for having taken a first small step toward mastering
their own health and that they must be prepared to the disease. Success here will give the educator
cooperate in order for medical recommendations credibility and will pave the way for a subsequent
to be successful. This may require, on occasion, comprehensive and systematic teaching
that an “ideal” medical recommendation—which program.
the person will not follow—be changed to one Primary teaching should focus on avoidance
that is less than ideal but which they are willing to of triggers and situations that make asthma
accept and carry out. worse. It should promote the effective use of
4. The person must recognize that the health- medication (by teaching the correct use of
care provider is a professional. Healthcare pro- devices). It should also deal with the required
fessionals must demonstrate they are medical communication skills that they will
knowledgeable and effective before individuals need (explanation of general medical terminol-
with asthma will follow their advice. This does ogy and anatomy, how to talk with their HCP)
not imply that only physicians’ advice will be and with preventive techniques, such as relax-
followed—many individuals are suspicious of ation exercises and stress management, that
physicians and may follow advice from other allow them to cope with current problems result-
health professionals. It is important however that ing from the disease. Primary teaching, in other
the professionals involved have qualifications words, should be on how, hopefully, to avoid
that are acceptable and appropriate. subsequent occurrence of illness.
5. Ongoing, customized education must be Secondary teaching should focus on stopping
available to help the person lead a near-normal the progress of the disease, preventing further
life (“lifestyle education”) and to teach the per- deterioration, and on steps to take when symp-
son about asthma, its treatment, and manage- toms worsen. Teaching should include:
ment. Teaching about asthma should be done
consistently and reviewed frequently, tailored to • Basic pathophysiology of asthma
the person’s age, maturity, and needs. An • Need for changes in activity or occupation
emphasis on an overall healthy lifestyle, with • Exercise techniques and appropriate use of
attention to diet, exercise, environment, and premedication before exercising
stress, is an important component of asthma • Explanation of the regimen
treatment. Attention to these issues must always • Training in the use and care of devices
be included along with more specific medical • Defining the expectations of the person and
items. the family and their responsibilities
394 11 Adherence
The educator should also discuss the emo- • Helping them to rest after each activity and
tional and other impacts of asthma on daily activ- before undertaking the next one
ities and on relationships with a spouse and • Maintaining a calm and restful environment
significant family members. • Positioning them for optimal breathing (usu-
This secondary level of teaching must be ally, sitting upright or leaning forward over a
individual-specific and based on an assessment pillow resting on a table)
of their needs and experience with asthma. The • Providing warm fluids to maintain adequate
following topics should be taught: hydration (cold fluids should not be given)
• Ensuring that the reliever medication is read-
• Adaptation to the health problem ily available to them
• Early detection of deterioration • Monitoring them and taking them to the hos-
• Awareness of the signs of deterioration pital if the reliever medication appears not to
• Recognition of the side effects of medication be working
• Control over some aspects of the disease
After the attack, family members can help the
All of these help them develop coping skills individual to try and identify the stimulant or
and mechanisms with which to face potential cri- trigger that caused the deterioration.
sis episodes. For children with asthma, short-term counsel-
Tertiary teaching involves anticipation of ing should also include simple precautions to
future problems and guidance toward coping take, so that the child can visit relatives (such as
with them as is necessary for any chronic condi- grandparents) who smoke or own a pet, or how to
tion. This is anticipatory guidance. prepare a child and the teachers to deal with
asthma while in school. It would even extend to
preparing a child to go to camp and to dealing
11.5.2 Anticipatory Guidance with social situations. Short-term counseling
should also coach them on how to anticipate and
Anticipatory guidance is a method of preparing respond to normal events as well as particularly
individuals and families for the problems encoun- stressful circumstances. Anticipatory guidance
tered in daily living that result from the asthma lets them know what to expect when they are
and its exacerbation. In addition, it also teaches required to go to the emergency department or be
skills that encourage personal growth and devel- admitted into hospital.
opment. In effect, it includes both short- and In summary, short-term anticipatory guidance
long-term education. is an integral part of the person’s asthma action
plan. It:
11.5.2.1 Short-Term Counseling
Short-term counseling should teach them how to • Identifies risky situations
handle an asthma exacerbation, both during and • Anticipates environmental triggers and factors
after the episode. This is where the asthma action that influence health
plan comes in. Family members can help during • Teaches them to cope with illness during
an asthma attack by [37]: attacks
• Providing assistance with daily tasks, such as 11.5.2.2 Long-Term Counseling

washing, bathing, and feeding, in order to for Parents
minimize the individual’s energy expenditure Anticipatory guidance also contains a long-term
• Reminding and helping them to use adaptive component. It must provide for growth and nor-
breathing techniques, such as pursed lips on mal physical, emotional, and intellectual devel-
exhalation, to decrease the work of opment. It must consider problems concomitant
breathing with age and disease.
For parents with small children, guidance stand the need for avoidance of triggers, or the
should embody both short- and long-term issues general lack of understanding that healthy people
[13]. In the short term, parents of preschoolers have for a chronic condition. In effect, long-term
who have asthma require help to: anticipatory guidance makes the parents of pre-
schoolers and kindergarten-aged children aware
• Monitor the medical regimen of problems that are likely to surface in the ele-
• Keep track of medications taken mentary school.
• Anticipate triggers Other hazards also need to be anticipated,
• Modify the home environment such as the problems of smoking and drug abuse.
• Avoid environmental triggers of asthma It is also at this stage that a child’s reliever medi-
cations may be stolen because they provide a
Over the long term, parents need different “high.” If parents are aware of these problems,
forms of advice and assistance. They need to they will be in a position to take preventive action
learn how to teach the child to take increased and to teach the child to cope with such situations
control of the condition at a level that is appropri- when they occur. This increases the child’s auton-
ate for the child’s age and degree of maturity. omy and sense of self and in doing so teaches
Parents must learn how to teach the child to self- both communication and negotiation skills [13].
monitor and self-manage the asthma. This is nec-
essary for the child to adjust to the reality of a 11.5.2.3 Counseling for Adolescents
chronic illness. The educator can help strike a In the teenage years, a fresh set of problems will
balance between the needs of the parent to moni- emerge:
tor the child and the need of the child to have
some control over what is happening. • The belief that taking medication is not fash-
Long-term considerations for parents of kin- ionable or “cool”
dergarten and preschool-aged children include • A reluctance to exercise if exercise is a
dealing with school issues and possible dietary trigger
restrictions, food contamination, and food • Increased tobacco and recreational drug use
exchanges away from home. They will need to • Social functions where smoking and alcohol
teach their child: use are encouraged by peers
• Friends who smoke, wear perfume, or own
• How to say “no” to figures of authority who pets.
might offer them food
• To resist accepting food that could be a trigger It is important for parents to be aware of the
(for a child with a nut allergy, this might adolescent’s self-image, social adaptability, and
include candy bars, cake, and any baked goods desire for independence [121]. Parents who are
containing nuts) too insistent on monitoring the adolescent will be
• To avoid allergens in school (which requires resented, while a lack of parental or adult super-
an awareness of their asthma triggers) vision will be seen as a lack of caring. A degree
• To deal with unsympathetic teachers, particu- of supervision is necessary, although this should
larly in physical education classes diminish with age and maturity. Parents should
not expect the adolescent to assume full responsi-
Family-related issues should be discussed. bility for the asthma. They should be encouraged
These may include concerns that another child to reduce their responsibility in overseeing the
may have asthma to the same degree of severity medication regimen to the same degree that the
or the fear of a pregnancy resulting in a child with preteen and early teenagers accept this responsi-
asthma. They will need help in resolving family bility. Sudden changes of responsibility should
conflicts that arise from one parent being a be avoided. The transfer should be done slowly,
smoker, or from grandparents who do not under- in keeping with the teen’s desire to have more
396 11 Adherence
autonomy and ability to handle increased respon- ered themselves as “disabled” and the focus
sibility. Parents must participate to some degree should be on their abilities. The appellation “dis-
in the management of the illness and must expect abled” is merely there to provide them with extra
some periods of nonadherence. help should they need it with particular reference
Adolescents list inconvenience, lifestyle to an asthma attack and not as an excuse to avoid
changes that are required, social embarrassment, doing the necessary work.
and side effects of medication (corticosteroids) as
their barriers to adherence [121]. They also list 11.5.2.4 Long-Term Counseling
forgetfulness, laziness, denial of asthma, embar- for Adults
rassment, difficulty in using inhalers, belief that Young adults in their early twenties may have
the medication is ineffective, and fear of side problems that are job- or relationship-related.
effects as reasons for nonadherence. Barriers to These young adults will be anxious to do well at
adherence also include self-image, social adapta- their jobs. They may be even more reluctant to
tion, failure to accept the asthma, duration of disclose that they have asthma fearing that it will
exacerbations, poor communication, low income, impact their job opportunities and career prog-
parental friction, and the absence of a father. A ress. Relationships will also be hampered with
strong sense of normalcy and self-motivation the need to avoid triggers such as perfume and
when combined with support from parents and pets. The effect that asthma has on their perfor-
HCP will aid adherence [122]. mance will be of pressing concern to them as will
Asthma does impose some physical limita- the effect of asthma on family functioning and
tions, and individuals with asthma will need to relationships.
learn to adapt to them. The asthma educator Occupational asthma is a concern for this age
should encourage them to exercise. Some forms group. Educators can help them come to terms
of exercise, such as swimming (which takes place with lifestyle and career changes that result from
in a warm, humid atmosphere), are preferable to such a diagnosis through discussion of job alter-
others. Downhill skiing is preferable to cross- natives and referrals to specialists, such as career
country skiing. However, if the teen is keen on counselors.
cross-country skiing, asthma is not a barrier. The The older adults often see asthma as one more
educator can strategize with the teen to develop a problem to add to a growing list of health con-
plan to allow them to exercise safely in the way cerns. Polypharmacy is a concern since increased
they want. Martial arts will develop confidence use of multiple medications increases the risk of
and a sense of purpose. Suggesting other options adverse interactions. Besides physical ailments,
for those whose asthma limits them is generally bereavement, loss of occupation, isolation, and
helpful. lack of family support (mainly due to distance)
Adolescents will also need guidance in their are factors that can influence adherence. The old
choice of careers, since certain careers could and sick have had to relinquish control over
expose them to allergens or other triggers. When health matters to others, and there is often con-
adolescents are planning for postsecondary edu- cern that asthma is yet another burden for their
cation, remind them to indicate that they have a caregivers.
disability when registering at their institution of Whatever the age, anticipatory guidance can
choice. This will allow their instructors to take help individuals with asthma envision problems
their asthma into consideration when dealing that they will encounter that will affect wellness
with occasions that are negatively affected by and healthcare. Awareness of problems can aid in
their asthma—for instance, they may require both avoidance and prevention. The asthma edu-
more time to complete an assignment or delay an cator can provide considerable assistance in this
examination due to an attack. However, no adjust- area. Anticipation allows for preparation and
ments will be made if they are not registered as helps diminish the anxiety that can be caused by
“disabled.” It is important that they not consid- new and possibly troublesome situations.
11.5.3 Skills Required by And assessment ascertains their perspective and

the Educator expectations pertaining to the asthma.
Counseling helps in setting realistic goals and
The three levels of teaching strategies require providing opportunities to express feelings and
three different skills. The educator must be adept verbalize concerns. Counseling will help restore
at: psychological resilience. There should be an
emphasis on abilities instead of disabilities. It
• Counseling—helping deal with fears, over- also implies fostering a sense of hope and con-
come emotional barriers, and develop coping nectedness with others.
strategies Teaching helps them cope with asthma and its
• Teaching—helping change behavior through management. It helps them maintain a realistic
education perception by providing information about the
• Planning—encouraging a search for family condition, its prognosis, what they can expect,
and community support (This support may be the purpose of each medication, and possible side
financial, pertain to caregiving, or be some effects. It helps identify triggers such as emo-
other form of help.) tional stress, fatigue, allergens, or environmental
changes that precipitate an attack.
Each of these three skills includes a subset of Individuals who have an unrealistic view of
skills. their asthma are shocked by each crisis and
Counseling requires reflective listening, group unable to respond in a suitable fashion. The per-
therapy, confrontation (on occasion), negotiation, son who expects one attack to be the entire extent
exploration, and assessment. Its purpose is to of the condition is thrown off balance with each
help the person achieve behavioral control over succeeding crisis and feels increasingly helpless
the environment and cognitive control over and unable to cope.
asthma information and its interpretation (such as Crisis management is essential when dealing
lung function tests and peak flow readings). It with a chronic illness such as asthma. It is vital
also provides decision-related control, permitting that a realistic view of the situation is maintained
them to select various alternatives such as the and any perception that leads to panic avoided.
most suitable relaxation or stress management They must be carefully taught how to evaluate a
techniques to use, medications to take, and when crisis, what steps should be taken and when, and
to call for further medical aid. at what juncture medical help should be sought.
Counseling requires assessment to determine The use of self-relaxation and breathing tech-
the emotional stage of the individual and the fam- niques to minimize anxiety as well as suitable
ily. There are losses concomitant with a chronic coping techniques must all be taught [123]. The
illness that must be identified and dealt with. National Cooperative Inner-City Asthma Study
Assessment includes those elements that contrib- (NCICAS) Psychosocial Protocol [124] found
ute to both the individual’s energy level and that asthma knowledge by itself did not help
knowledge of the condition. Any loss of control those with asthma make appropriate decisions in
may induce depression and a belief that the situa- critical situations. Hence, the educator must teach
tion is beyond management. Factors that contrib- them what to expect and how to solve problems
ute to their sense of powerlessness need to be in acute situations.
identified and those that increase the sense of Teaching also involves giving instructions on
control recognized and emphasized. Assessment how to conserve energy through adequate rest,
also recognizes their ability to cope, their current proper nutrition and sufficient fluid intake.
emotional status, and attitude toward the condi- Teaching crisis management is an opportunity to
tion. It identifies the support system within the involve the whole family and extended support
immediate environment of the family and the system. The educator can explain what happens
larger social environment in which they exist. during an asthma attack and involve the individ-
398 11 Adherence
ual members of the family in role playing so that • Recognition of cultural, ethnic, and religious
each person knows what to do. This approach factors
emphasizes the seriousness of the situation and • Acceptable, affordable, regular treatment that
develops the support the person needs particu- provides continuity of care
larly when in crisis. It furthers the family’s under- • Development of treatment goals
standing of asthma and encourages the • Teaching of delivery systems, with consistent
development of suitable coping techniques. repeated checking of technique
When done properly, it balances the family’s • An agreed plan to recognize deterioration and
demands against its available resources, helps the the action(s) to be taken when deterioration
family adjust its perspective of the situation, and occurs
results in consolidation of these factors with a • Incorporation of peak flow measurement and
reduction in the level of stress and an increase in monitoring of the asthma into a regular
the family’s belief in its ability to cope [37]. schedule
Individuals who are involved with their treat- • Review of the home environment
ment, and who see themselves as part of a team, • Development of a support system
will develop coping mechanisms to meet each • Increasing the individual’s knowledge of
crisis situation. asthma
Planning is part of coping. This is anticipatory
guidance. Individuals who know what to expect The items have been listed above in order of
when they go to the emergency department, or effectiveness for most individuals with asthma,
are admitted to hospital, have a reduced level of always assuming that device teaching has been
anxiety. Planning helps them focus on the future done and reviewed consistently. It will be noted
and to anticipate events after the crisis. Planning that a general increase in the person’s knowledge
puts the exacerbation in perspective. of asthma, while important, is not the most
Emotional needs are generally indicative of important requirement.
learning needs, and it is imperative that the edu- It is essential to accept and understand the per-
cator understand when to focus on the former son with asthma as an individual before any
rather than the latter, since the goal, after all, is attempt is made to educate and achieve adher-
for both the individual and the family to function ence. This requires a basic understanding of atti-
at the highest possible level and to live a life as tude, beliefs, and feelings toward health and the
normal as possible. Asthma should not be viewed asthma [127]. External factors that can have a
as being totally restrictive and inhibiting but major influence on the degree of adherence
rather as a condition that requires adjustment of involve the social support, resources, and role
expectations. models available to them. Without an understand-
ing of these important factors, any approach will
be doomed to failure.
11.6 Specific Aids to Adherence Cultural factors influence the degree of adher-
ence they will show, how they respond to differ-
A specific approach to education, and a reduction ent approaches, and how they handle the
in the barriers to nonadherence, will include the morbidity associated with asthma. This would
following elements [37, 53, 113, 125, 126]: also include the way they handle their own feel-
ings, their willingness to discuss health matters,
• Acknowledgment of losses due to change in and even referral to other specialists or agencies.
health status Agreement on treatment goals is of para-
• Recognition of their fears, together with mount importance. In cases where the health-
opportunities to express those fears care professional’s goals and their goals for
• Understanding of internal and external factors treatment are widely different, it is very unlikely
that affect the individual that advice will be followed [128]. Not only
should time be spent on this issue, but the treat- Some individuals with asthma are given more
ment goals should also be put in writing. When than one preventative medication, and unless the
healthcare professionals are asked for treatment asthma is very severe, this will create a regimen
goals, they should include a measure of activity, that is difficult to follow. The combination of two
a comment on ability to sleep, and a listing of medications in one device may prove to be very
frequency of bronchodilator use. Some version helpful. When two medications are used with two
of these goals needs to be accepted by the indi- different devices, there may be increased cost,
vidual, and the precise meaning of these general and this may be an additional reason for the regi-
goals for a specific individual must also be men not being followed. Differing instructions
mutually agreed. for two devices can almost certainly lead to
Knowledge of the delivery system is as impor- confusion.
tant as the assessment of treatment goals. There If cost is a factor, individuals and their fami-
are many different delivery systems for asthma lies should be encouraged to explore social
medication (see Chap. 7). None is inherently resources such as Medicaid, Crippled Children’s
superior in all situations, and a thoughtful review Programs, and Social Security Disability
of advantages and disadvantages with an indi- Insurance [37].
vidual will lead to an effective choice. At the time The financial costs of medication can be a
of diagnosis, it may be better to prescribe one major deterrent to adherence. The asthma educa-
suitable device. More extensive choice and selec- tor can help by telling them about assistance pro-
tion can come later. grams. However, not all asthma medications and
The use of the delivery device should be devices are covered. Aside from the official
reviewed at follow-up visits, and teaching on this Medicare website that has information about
issue should not be confined solely to the initial public and private prescription medication assis-
visit. There may be full understanding and agree- tance, there are many websites available at the
ment on a delivery system in a clinic, but once time this was written, including the pharmaceuti-
they go home, attitudes may change. Recent stud- cal companies, to name a few, such as:
ies indicate that device usage technique deterio-
rates in as little as 2 weeks, hence the need for a • AstraZeneca—AZ&Me prescription savings
review of correct device usage during every fol- program at www.azandmeapp.com
low-up visit. This will help develop self-care • Boehringer Ingelheim—BI Cares assistance
skills and is essential to adherence and asthma program at www.boehringer-ingelheim.us/
control. our-responsibility/patient-assistance-program
Most individuals with asthma will need regu- • Forest Therapeutics at www.patienceassis-
lar medication. The medication regime must be t a n c e . c o m / p r o fi l e / f o r e s t p h a r m a c e u t i
simple, adequate, and adapted to their lifestyle. calssinc-148/
For example, some individuals have an abnormal • GlaxoSmithKline Inc with GSKForYou at
fear of inhaled corticosteroids and are unlikely to www.GSKForYou.com
follow such prescriptions without extended and • Merck at www.merckhelps.com
repeated reassurance and explanation. Some • Pfizer at www.PfizerRxPathways.com
treatment regimens are nearly impossible to fol- Other websites available are:
low, for example, when instructions are given to • RxAssit.org, a nonprofit organization with a
use medication four or five times per day. It is comprehensive directory of prescription drug
unrealistic to expect that this will be followed, assistance programs.
especially in the long term. • RxHope, a web-based resource that locates
Once the treatment goals and delivery systems assistance programs.
have been reviewed, understood, and agreed • Needymeds.org, a nonprofit that provides
upon, an acceptable regimen of regular treatment information on pharmaceutical assistance pro-
can be devised. grams as well as on free and low-cost clinics.
400 11 Adherence
• For low-income seniors and the disabled, the Asthma can be frightening, and learning how
National Council on Aging has the Center for others cope with it can be helpful. Suggest that
Benefits Access at www.ncoa.org/ the person who has asthma and their family
centerforbenefits. members get more help and develop a network of
• Many states, pharmacies, and nonprofit orga- support from self-help organizations and support
nizations offer drug discount cards. groups. This will allow the family to move toward
• For low-income, uninsured individuals, there acceptance and toward focusing their attention on
is a program to help them get free or low-cost other positive aspects of their lives. Almost all
brand-name medication through a program healthcare professionals accept that those with
sponsored by pharmaceutical companies and asthma need to know more about asthma.
advocacy organizations. It provides a search Nevertheless, it is possible to have asthma, com-
engine and can be found at medicineassistanc- ply with treatment, and have an enjoyable life
etool.org. with a minimal understanding of the condition.
• The Health Resources and Services Individuals with asthma should be allowed to
Administration site www.hrsa.gov provides decide how much they want to learn about
information on community health centers that asthma. Learning about asthma will take time,
may offer help to low-income persons. The and again individuals should be allowed to pro-
phone number is 1-888-ASK-HRSA. ceed at their own pace.
• www.patientassistance.com/programs.html There are many fears about chronic condi-
offers prescription assistance. tions, such as asthma, and fears also about the
treatment. These must be explored. Some indi-
Deterioration is such an important issue that viduals may be more fearful of the treatment than
time must be spent explaining how and why it the condition, and they will be unlikely to take
occurs, its usual causes, and how to identify it. To asthma medications. There may be other fears
go along with the recognition of deterioration, a such as loss of a pet or of a partner who is attached
plan on how to cope with deterioration must be to a pet or who smokes. Open discussion of such
discussed. This should be negotiated, put into fears is very helpful and is essential before a
writing, and be very clear. There should not be good, workable plan can be developed.
any possibility of misunderstanding. This is the At every visit, time must be set aside to deal
asthma action plan. with issues of adherence. To avoid any misunder-
The importance of peak flow values, as an standing, all items in this chapter must be
indicator of deterioration, needs to be taught. reviewed. It is important to find out if there have
Teaching of peak flow alone, without a review of been other healthcare issues such as new diseases
the other signs and symptoms of asthma, will not or alternative treatments, as these may also affect
lead to an improved knowledge of deterioration. adherence. The frequency with which such a
Further, peak flow meter technique itself needs to review is required will vary considerably from
be reviewed constantly. one individual to another. Even when there is a
Educators must review the home environment, full understanding of the issue and an ability to
and sometimes, home visits are important. There afford treatment, some individuals will be unable
are some obvious issues in the home such as the to follow a regular treatment plan. Such nonad-
number of smokers, the number and behavior of herence is very harmful and is associated in some
pets, the humidity level, type of heating, etc., but families with abnormal psychosocial factors. In
other factors such as the attitude of the individu- such a situation, the help of a psychosocial pro-
als and their family to their home environment fessional is important. Consideration must then
are also important. Once the home environment be given to the appropriate professional referral.
is known and the attitude of everyone in the home Fortunately, such cases are uncommon.
is understood, strategies can be developed jointly Specific approaches to adherence should
to improve that environment. include the use of [3, 7, 8, 52, 53, 118, 121, 129]:
• Behavioral techniques, which tailor the medi- Soon after the initial diagnosis, they will enter
cation regimen to the individual’s lifestyle. a transitional phase in which they begin to under-
The number of lifestyle changes needed in stand the condition and combine that knowledge
order to incorporate a prescribed regimen with the asthma-related skills and experience that
must be minimized, and they should be are concurrently being acquired. Then, self-
encouraged to become involved in the treat- awareness skills begin to develop, followed by
ment to the extent permitted by his or her acceptance and a conscious effort to control the
limitations. condition. These skills then morph into self-
• Self-monitoring and feedback techniques management skills that they then unconsciously
[40], which are essential so that they may not fine-tune over time, till they are well-adapted to
only predict deterioration in asthma but also helping manage the asthma [131, 132].
help feel that they are part of the treatment A knowledgeable caregiver can help them tra-
process. verse these phases, thereby reducing the initial
• Simplification of regimen, so that the fewest high level of fear. Continuing support can help
doses of medication are used for the least them gain control and understanding of their par-
number of times a day, with the smallest via- ticular pattern of asthma [52]. The person with
ble number of devices. Linking the taking of asthma will have continuing cognitive and emo-
medication with routine tasks can help them tional adjustment to the asthma until acceptance
remember to take the medication. In other is reached.
words, the medication regimen should be tai- They need to grow in confidence and in self-
lored to fit daily routines [40, 130]. efficacy (the belief that they can do what needs to
• Scheduled appointments and follow-up, to be done), so that strong evaluation and decision-
ensure that they spend minimal time in the making skills are developed. Decision-making
waiting room and more time with the physi- ability is very important and a skill that every
cian and/or asthma educator. The follow-up is person needs, especially on a practical level. It is
needed in case they have additional questions the skill that most strongly affects the quality of
about medications, side effects, dosing, treat- life. Social psychologists look at decision-making
ment plans, etc. It is also a strong reminder to as conflict resolution.
them that other HCPs are involved in the care Decision-making is a teachable, logical, sys-
of the asthma and is often seen as indicative of tematic process. To begin, the individual must
the measure of concern. recognize that a problem exists and then be able
• Improved individual-provider interaction. to articulate (formulate) it. Next, additional infor-
• Support and positive reinforcement while fos- mation about the problem must be obtained, so
tering a warm and caring attitude among all that viable solutions and alternatives can be iden-
team members. tified. Finally, a course of action must be selected
(i.e., a decision must be made) and carried out.
For most individuals with asthma, adherence Cognitive processes play a significant role in
is encouraged when the physician, educator, and decision-making, as do attitudes, beliefs, and
pharmacist work together as a team and recog- fears. Anxiety and stress interfere and adversely
nize that the individual and family are the most affect decision-making behavior.
important members of the same team. Those individuals who rely on healthcare per-
sonnel to solve their problems will go from crisis
to crisis, feeling more and more helpless with
11.6.1 Self-Management of Asthma each new crisis. Those who are taught self-
management skills and learn how to apply them
While self-management is the ultimate goal, will work toward the resolution of the crisis with
those with asthma must pass through stages the help of their asthma team. The former will
before acquiring this ability. live in a constant state of crisis, unable to func-
402 11 Adherence
tion normally, waiting for the next crisis to occur Thus, self-management [38] requires continu-
while increasing their dependence on the health- ous awareness, judgment, or assessment of risk
care system. The latter, on the other hand, will and the ability to make choices, to manage envi-
live as normal a life as possible while prepared ronmental and physical demands and to balance
for the unexpected. They will try new things, conflicts between them. What then is expected of
knowing that help is on hand should circum- those who achieve self-management? A complex
stances get out of control. They will also see medical regimen that requires daily use of medi-
exacerbations as a temporary lack of control, or cation must be understood. Self-management
as transient disruptions in family and community also comes with the requirement to distinguish
life, and be far better prepared both emotionally between acute and daily use of medication, to
and mentally to cope with the asthma. increase dosages depending on the severity of
Self-management is a process that proceeds symptoms (preferably according to an Asthma
from full dependence to increasing independence Plan), to judge when the severity of an episode
of actions. It requires that they, on observing requires medical assistance, to be constantly
symptoms, assess the threat and determine a aware of possible environmental triggers, and to
response (see Fig. 11.2). Observation leads to decide how best to avoid them or to minimize the
monitoring of symptoms and their evaluation in effect of these triggers. They have to deal with:
order to determine whether they are unchanged
or deteriorating. The next step is based on their • Multiple medications
self-confidence to handle the situation and this • Different methods of delivery
leads to a response. A decision has to be made • Frequency of negative side effects
and the dilemma solved. This may be one of three • A complex medical regimen
choices—avoid and prevent symptoms, stay and • A preventive rather than curative process
manage the resulting bronchoconstriction, or • The impact of asthma on self, lifestyle, and
delay treatment with the possibility of an attack social environment
later. • Periods of remission
The evaluation of the threat is done on a risk/
benefit basis, and some may choose to stay in an Personal decisions must be made in a health-
asthma-inducing situation because they believe care field that is in itself intimidating and where
they stand to gain something which in some mea- the choices may themselves be daunting. Self-
sure they would lose if they left. For instance, a management demands time, serious effort,
teenager will remain in a smoky environment in unvarying attention, and constant
order to stay with friends rather than leave and be decision-making.
alone. Knowledge alone will not help in developing
the necessary self-management skills. Personal
behaviors that need to be modified and those
that can be changed must be identified.
Conscious effort is demanded to amend long-
established patterns of behavior, thinking, and
coping. Moreover, sustained effort is required to
maintain the new behavior [133]. In effect, a
high level of self-control and awareness is
required.
Successful self-management of asthma
requires skills for attack management, preven-
tion, and social skills [128, 134, 135]. These
include a subset of skills such as self-monitoring,
Fig. 11.2 The path to self-management self-evaluation, and self-reinforcement.
It is the job of the asthma educator to help in before symptom relief occurs. They need to know
the development of these skills and to teach the that a reduction in the time span of effectiveness
specifics of the necessary skills. Development of of a bronchodilator is an important indicator to
these skills [8] requires instruction, practice, seek medical help.
reinforcement, and encouragement. Further, the Panic and extreme anxiety may accompany an
person with asthma must sincerely want to increase in dyspnea due to asthma. The complex
develop these skills before they will make the web of relationships between asthma, panic, and
genuine effort required to attain the necessary other behavioral states is described well by Creer
proficiency. Learning new skills requires both et al. [7]. While this review was directed toward
effort and time. Confidence will result from prac- children, the conclusions apply to persons of any
tice, and repeated success will reinforce their age. The hyperventilation of panic, perhaps with
ability, their self-confidence, and adherence. a mechanism similar to the hyperventilation of
exercise, may increase the airway reactivity
11.6.1.1 Attack Management Skills already present.
Handling an asthma exacerbation involves know- Techniques that lessen panic, such as standard
ing how and when to: relaxation exercises, may help in breaking out of
this vicious circle. Relaxation techniques may
• Rest and relax. have more wide-ranging benefits in helping them
• Remain calm. to be calm during periods of asthma exacerba-
• Act promptly. tions. A calm person will, overall, make better
• Use medications appropriately. decisions.
• Monitor the progress of therapy. They need to know which medications should
• Maintain adequate hydration. be increased, both in dosage and frequency, and
• Seek medical help when necessary. above all when and how to seek medical help.
This is an integral part of the written action plan
Those with asthma may frequently lack the [39, 124]. They must be taught how to read peak
skills needed for self-observation or may lose the flowcharts, to collect daily diary data, to monitor
sensation of dyspnea or may assume that an symptoms, and to interpret conclusions so that
asthma attack occurs suddenly. Once they deterioration is treated at the earliest possible
become aware that an asthma attack is generally moment. Awareness of the late-phase response
the result of slow deterioration and is preceded can be helpful in making decisions.
by a number of warning signs, they increase their An individual with asthma who is skilled at
awareness of their own signs and symptoms. self-monitoring will be able to recognize asthma
They must be taught how to constantly self- symptoms, be aware of physiological responses,
observe themselves in order to monitor their health be cognizant of triggers present, and understand
in an ever-changing environment. They need to be the psychological response to the total environ-
aware of the signs and symptoms and be able to ment (which spans all personal relationships and
differentiate between the early warning signs and includes the influences of race, religion, culture,
the danger signs of asthma (see Chap. 1). These and health beliefs).
skills can be acquired over time and must be pres- Self-monitoring facilitates changes in behav-
ent before treatment decisions can be made when ior. It is the first step to making lifestyle changes
deterioration occurs. and avoiding triggers. The self-understanding
They need to know what to expect from the gained as they recognize symptoms, chart the
prescribed therapy, for the simple reason that occurrences, and document the circumstances
expectations play a major role in adherence. They that lead to asthma exacerbations, identify new
should be able to monitor the level of improve- triggers and thus the individual pattern of asthma,
ment they obtain from the prescribed medication, leads to the awareness and development of pre-
with particular reference to the time needed vention and decision-making skills [40].
404 11 Adherence
11.6.1.2 Prevention Skills when using a peak flow meter. Having said that,
This set of skills involves monitoring, self- parents must at the same time encourage the
observation, and self-evaluation. It includes an child’s growth in independence in asthma man-
understanding of the physiological responses to agement. School outings, examinations, parties,
triggers and a knowledge of the outcome of an sleepovers, and other social events may require
action (or lack thereof—such as knowing that anticipatory increase in treatment [93].
staying in a smoke-filled room will cause deterio- For adults, self-reinforcement occurs when a
ration in lung function). It also involves self- benefit of some type is obtained from an action.
recording (symptoms and/or peak flows in a The benefit may be a reduction in symptoms or
diary) so that the person can process and interpret maintenance of peak flow. For instance, the per-
data, anticipate possible triggers, and make son may observe a dip in peak flow readings after
appropriate decisions [7]. Together these skills exposure to a trigger. Once they connect the two
provide the ability to: events, they may be able to avoid the next expo-
sure so as to prevent a reduction in peak flows.
• Recognize warning signs of deterioration Self-reinforcement can occur through daily
• Act to prevent an attack charting or experience and be either positive or
• Identify triggers negative. It is part of the learning process.
• Avoid triggers
• Take medications as required 11.6.1.3 Social Skills
Primary among the social skills are communicat-
People with a history of repeated attacks need ing with HCP and handling problems at work or
to be able to identify the pattern—whether of school and at social events.
events, triggers, or other factors—that precedes While emphasis is placed on communicating
an attack. Many tend to be unaware of their pat- with HCP, one should not forget family members
tern and approach each new activity with fear in and the need to communicate clearly with them.
anticipation of yet another attack. The chronicity Individuals or the parent/caregiver of a person
of asthma tends to build a feeling of helplessness with asthma must be able to inform and teach
and inability to cope with the asthma, which is other members of the immediate family about the
not just variable but totally unpredictable. They condition and also explain the reasons for pre-
can lessen their fears and increase their self- scribed medications and environmental recom-
confidence by: mendations. This is critical, because an individual
without family support will find it difficult, if not
• Discovering their own pattern(s) impossible, to adhere to an action plan and avoid
• Identifying possible triggers triggers.
• Learning techniques to avert or avoid triggers In order for people with asthma to learn how
• Learning to monitor and assess asthma to communicate with HCPs, it is important that
severity they understand the common medical terms, such
• Learning to premedicate when necessary; as inhaler, bronchodilator, corticosteroid, aller-
• Learning to adjust medications and follow an gens, antibodies, immunotherapy, nebulizer, and
asthma action plan so on. Clear communication cannot take place
where there is a margin for misunderstandings.
Parents with children who have asthma need Individuals with asthma and HCP must under-
to work diligently in recording symptoms and stand each other unambiguously when discussing
peak flows in order to recognize trigger patterns, the condition and its medical regimen. There
anticipate possible triggers, and make appropri- should not be room for miscommunication.
ate decisions pertaining to medication and the A national survey by Cabana et al. [136] asked
need for medical help. Children must be super- 896 parents to assess specific asthma symptoms.
vised during the taking of medication and even Ninety-six percent described their children’s
asthma as being under “good control.” When spe- concern. For reasons such as this, they may be
cific questions were asked, 34% actually described reluctant to inform coworkers or school person-
what asthma educators and HCPs would consider nel that they are unable to function at their nor-
poor control. Medicaid insurance and parental mal level. There is always the stigma of chronic
smoking increased the risk of misinterpretation of illness to be dealt with, and an admission of ill-
the questions asked. Misinterpretation was ness may be a major factor in restricting advance-
decreased with education about asthma and where ment in the workplace. Individuals who have
English was the primary language. occupational asthma may have grave concerns
It is the role of the asthma educator to help the about the possibilities of changing careers, par-
individuals: ticularly as they reach middle age. They may be
fearful of change and the possibility of obtaining
• Understand all the medical terminology used. employment in a different field. They may be
• Ask the physician questions, and request a reluctant to apply for employment that offers less
referral to a specialist when there is doubt in the way of financial rewards. They may be
about the diagnosis or treatment or there is an reluctant to discuss the asthma and its financial
unusual degree of anxiety. implications.
• Avoid embarrassment when asking for infor- It would be helpful if the asthma educator
mation on the medications, other medical mat- does some role-playing and helps the person
ters, or any areas of concern. learn how to be assertive in the school or work-
place. Observing the educator enacting a meeting
Communication is vital to the success of edu- with an authoritarian figure can motivate them. It
cating individuals and their families. This also can also help them anticipate difficulties and
applies to school and work settings. At school, practice an approach that is non-confrontational.
they may be faced with lack of knowledge by Both role-playing and modeling are useful tools
school personnel and the difficulty of explaining in reducing anxiety and in learning how to cope
an invisible condition. Problems will occur when [40].
there is lack of communication between parents The essential social skills needed by the per-
and teachers, particularly when teachers are not son with asthma include communication and
told that children have asthma or severe allergies. negotiation. They need to enlist others in their
Problems can be anticipated—for example, in attempts to avoid triggers and manage their
physical education classes that do not provide asthma. Self-help groups can offer empathy, sup-
adequate rest periods, disallow pre-medication, port, understanding, and suggestions. They are a
and place unnecessary restrictions on students resource that should be recommended. Often
with asthma. All school personnel from teachers members in such a group have dealt with similar
to school bus drivers must not only be aware of problems and can offer possible solutions or sug-
those students who have asthma but also know gestions about ways to successfully communi-
what to do in the event of an emergency. cate and negotiate with coworkers, family, school
Problems may arise when the individual needs personnel, health professionals, supervisors, and
to discuss asthma with family members who may members of their social milieu—all in order to
or may not appreciate the problem. Problems also provide an optimal control of the person’s asthma.
arise in communication with health profession- Caplin and Creer studied individuals 7 years
als, especially when explaining the difficulty in after the completion of training in self-
avoiding triggers and financial concerns. management. While some individuals continued
Asthma is a chronic condition. Further, there to use the self-management skills, others had
are no external signs of whether the person with relapsed. Those who had continued to use their
asthma is feeling slightly unwell or sick. Even skills did so over a broad range in order to main-
wheezing may be dismissed by companions or tain control over their asthma. The most surpris-
coworkers as noisy breathing and no cause for ing finding was that even the so-called relapsers
406 11 Adherence
regularly used some of their self-management will reoccur or that it can worsen with exposure
skills, generally those pertaining to self- to triggers. High levels of stress and anxiety may
monitoring, to prevent exacerbations [137]. cause them to feel that they cannot cope, so that
they then react (in effect, cope) by denying the
diagnosis. Those with high-risk lifestyles who
11.6.2 Health Education abuse alcohol and/or take illicit drugs may view
asthma as one more added burden, and simply
Learning the appropriate asthma-related skills choose not to deal with it. Above all, lack of fam-
requires time, effort, and repetition in order to ily support is a major hurdle to adherence. Since
build behavior patterns. Individuals with asthma asthma is a condition where environmental con-
will not comply unless they understand: trol is the first line of defense, the consideration
and cooperation of other family members
• Why a certain behavior can be beneficial becomes crucial.
• How to act so that it will be beneficial People do not attend asthma education pro-
• The personal benefits of appropriate behavior grams for many reasons, including:
This is the essence of the teaching process. • Socioeconomic status

Successful educators make learners aware of the • Denial
benefits so that they may make informed choices. • Occupational asthma
They must be given the opportunity to exercise • Illiteracy
those choices, because behavior change has to be • Depression
individually motivated. Health education there- • Anxiety
fore should not only provide knowledge and • Lack of interest
skills but also motivation in the development of • An inability to see the need
those skills as well as a positive attitude—all • Being a visible minority
within a supportive environment [91, 92]. Health
education also reduces fear and anxiety. Because Too often they accept the discomfort and
it can also offer the possibility of alternate behav- restrictions imposed by asthma because that is
iors, it can help individuals control their asthma what they expect from it. They are unaware that
and improve their quality of life [138, 139]. asthma education can make a significant differ-
A number of factors [93] work against adherence. Based on previous experiences or second-
ence. They include: hand knowledge of asthma, they assume that
medication will suffice to control it. They do not
• Denial of disease see a need for education. Whatever the reasons
• Social isolation behind their behavior, the physician and the
• Depression asthma educator must discover it and help them
• Family conflicts deal with it and work toward adherence.
• Anxiety, shame, and/or anger It is essential to remember that, in order for
• Life crises the results of adherence to be maintained, it must
• High-risk lifestyles concur with the individual’s:
• Alcohol and/or tobacco abuse or use of illegal
drugs • Personal goals
• Psychological status
Individuals with asthma may choose not to • Functional status
believe a diagnosis. To many, unaware of is chro- • Use of healthcare
nicity, a single attack that is reversed is indicative
of the typical nature of asthma. Hence, there may Individuals who do not see education as part
be reluctance or refusal to believe that the asthma of a personal objective are not likely to concur
with any proposal put forward by the physician/ It is hence imperative that the person with
provider or the asthma educator. If the suggested asthma be both an integral part of the asthma
objective does not meet their expectations, they management team and a willing participant in all
will not collaborate, and any possibility of adher- treatment regimens and goals. One significant
ence is nullified. Psychological status is indicated reason why this often does not happen is because
by them when they are ready to learn, free of they and the HCP lack an understanding of each
overt stress, anxiety, and fear. other’s cultures or are unable to communicate
They must be ready not only to learn but also effectively [6]. Some of the cultural roadblocks
to participate in the process. Willingness and are briefly described next.
health status is associated with functional status.
Sick people are unable to focus on or retain infor-
mation to the degree required for behavior 11.7 Cultural and Religious
change. They have to be able to physically per- Differences
form a required behavior for adherence. Inability
to understand, follow through, and execute a According to Culturally Competent Nursing
desired behavior are all reasons for nonadher- Care: A Cornerstone of Caring, PCC “involves
ence. Finally, if they feel that the best way to treat being aware of the role of cultural health beliefs
asthma is at the emergency department, the and practices in a person’s health-seeking behav-
asthma educator must work harder to help them iour and being able to collaborate with individu-
understand that they can control the asthma at als and negotiate treatment options appropriately
home. Consider the real-life case of the nurse and in a culturally sensitive way” [141].
who phoned the asthma educator to ask why an People with asthma come from all walks of
asthma action plan was needed. She had her own life and from every conceivable ethnic and cul-
plan, which was to see her physician every time tural group. Each of these groups has its own
her asthma got worse. She was not willing to con- mores, values, customs, and defined behaviors,
sider an alternative or take control of her asthma. and those group “standards” affect their views of
Individuals such as these are a challenge to the world and the authority figures (such as HCP)
educate. within it. To further complicate matters, while
The Institute of Medicine has defined patient- first-generation immigrants exhibit many of the
centered care (PCC) as one that “establishes a behavioral and community traits of their home-
partnership among practitioners, individuals and land, their children will in all probability have
their families (when appropriate) to ensure that enthusiastically adopted the lifestyle and think-
decisions respect patients’ wants, needs, and ing patterns of their adopted country and will in
preferences and solicit patients’ input on the edu- many ways be completely different from their
cation and support they need to make decisions parents.
and participate in their own care.” The NAEPP Cultural and ethnic values play a major role in
Guidelines [52, 116] repeatedly emphasize the dictating the types of behavior that are deemed
need for teamwork and partnership that involves acceptable and how feelings, methods of coping,
the individual and the family. It emphasizes that and even depression are expressed. Behavior is
goal setting should be done with suggestions and learned through cultural patterning. Culture
input from them and should take into consider- affects symptom recognition, morbidity, and
ation their needs, knowledge and beliefs, health treatment [68, 142]. Further, mortality rates for
literacy, culture, and ethnicity. PCC is also called diverse ethnic groups differs from one another
patient-focused care (PFC). and from Caucasian rates [143].
PCC has been shown to improve physicians’ For the healthcare professional who is trying
performance, increase individual satisfaction, to obtain a person’s trust, the cultural minefield is
and improve health outcomes without requiring a major challenge and one in which they must
additional time or resources [140]. tread very, very carefully. Simple gestures that
408 11 Adherence
might seem perfectly innocent in North experience, and are treated with deference and
America—such as sitting so that the soles of respect. Older adults of Asian, Middle Eastern,
one’s shoes directly face the person—are viewed and Filipino [146] origin, especially, will expect
as highly insulting in many Asian and African the HCP to have a respectful attitude toward
cultures. And the list of such cultural faux pas is them. Impatience or hurried instructions will be
extensive. seen as disrespectful.
The HCP must ensure that behaviors which
offend a person of another culture are avoided, Older adults’ beliefs will often be very differ-
even if such behaviors are acceptable in the pro- ent from those of the younger generation. They
fessional’s own culture. As such the HCP must be may believe in traditional methods of healing and
aware of the ethnic groups, the different reli- may practice covert nonadherence. In particular,
gions, and the cultural minorities whose medical they may dislike the assertive and informal atti-
needs are served by the clinic or hospital [52, tude of the West. Older adults, especially immi-
144]. At the same time, it must be remembered grants, will be unlikely to share their feelings
that there will be wide variations in behavior and with people outside their family. This practice is
observances even within one ethnic group, both reinforced when there are language differences.
in terms of culture and religion. Some individuals They tend to be family-oriented. In such cases,
will carefully comply with their cultural and reli- the asthma educator will find that compliance is
gious practices, while others will be lax or simply easier to obtain when other family members are
not practice their religions. The educator should involved in the treatment.
never assume that a person will refuse certain
treatment options because of religion or culture. Ask the person about their religious beliefs and
Instead, the educator should describe the pro- practices It is important not to make assump-
posed treatment and ask them whether it will tions based on appearance or name. Different
offend or go against any of their principles or religious requirements can pose different chal-
religious beliefs. lenges. For instance, Muslims (followers of
While there is little documented research on Islam) are required, during the period of
those behaviors or styles of interaction that can Ramadan, to fast from sunup to sundown. They
give rise to misunderstandings involving individ- will not take any medications during these hours.
uals from different cultures, certain guidelines Hence, a requirement for asthma medication to
can be used to ensure that the educator does not be taken three times a day will not be observed. It
unwittingly offend them. In an ideal situation, the may be necessary in such cases to ask them to
educator would be familiar with the beliefs and request special permission from the Muslim
culture of each individual—this may not be pos- cleric or imam.
sible—hence the following suggestions [145]:
In religions which ban the consumption of
Treat the person formally during the first visit or beef, capsules made of gelatin derived from beef
visits Address the individual formally by sur- will not be acceptable. For religions that ban the
name, using the prefix Mister or Ms. as appropri- consumption of alcohol, it should be remembered
ate. Do not use their first name. (Using the first that QVAR and Proventil contain ethanol, an
name without being asked to do so may be seen alcohol.
as both impolite and offensive familiarity.) Ask In order to build a good and working rela-
how they wish to be addressed. Be polite and tionship with a person, the HCP must establish
show genuine interest. rapport [147]. One way of achieving this is to be
aware of the person’s major religious holidays.
Treat the older adult with respect In most coun- It is helpful for the asthma educator to keep a
tries, senior citizens are seen as valued members list of the major religious holidays handy for
of the community, and as sources of wisdom and reference.
Be aware of the “sense of space.” North Asian Indians, dislike being touched, and touch-
Americans are used to having a considerable ing the head is particularly abhorred, since the
amount of space between and around them. This head is deemed the site of the soul, so that one
“personal space” is reluctantly given up when should never touch the head of another person,
necessary—for example, when riding in an eleva- especially a child. Touching a person while argu-
tor or on a bus. As an aside, during the COVID-19 ing is prohibited in many Eastern cultures since it
crisis, elevators are less crowded by design and is indicative of loss of self-control, as is raising
often have limited spots marked on the floor your voice.
where passengers can stand. Many immigrants
come from countries where space is at a pre- Interpret smiles correctly Be aware that a per-
mium. As such, they do not feel uncomfortable son may smile for many reasons, not merely as an
standing very close to other persons or to the indication of happiness. In many cultures, a smile
asthma educator while talking. However, with the is used to mask awkwardness or embarrassment
emphasis on “social distancing” during the or as a polite negative or form of criticism. If an
COVID-19 pandemic, this behavior may be immigrant, on being asked for an opinion about
changing. Nevertheless, some individuals will something, responds with a smile, the person is
continue to do this, which may make the asthma most probably disagreeing in the politest way
educator feel uncomfortable. Should the asthma possible. A smile can express many emotions and
educator move away, the immigrant person would a variety of responses.
probably interpret such a movement as disap-
proval or as an indication that the conversation is Understand “politeness” In many Eastern cul-
about to be ended. The asthma educator must be tures, disagreeing with a person in authority
on guard for subconscious behaviors of this type. (such as the educator /nurse/physician) is seen as
unmannerly. Hence, the person, while silently
Make eye contact with care In mainstream disagreeing, may make sounds of agreement. The
North American culture, eye contact is used as an educator then must try to not place them in a
indication of honesty and interest. This is not true position where they have to disagree and must be
for native Americans and Asian Americans and sensitive to their responses.
for people from many Eastern cultures. In these
groups, eye contact is seen as threatening, aggres- Do not cause loss of face Many cultures will
sive, confrontational, or hostile. It can also be avoid verbal comments that draw attention to a
regarded as both disrespectful and rude. Hence, person. This is interpreted as loss of face. Persons
maintaining eye contact may have a negative from these cultures will avoid situations that can
effect on the individual. cause embarrassment because of the potential
loss of face. Disagreement with others is such a
Be cautious about touching Touching is a part cause. Dignity and poise are considered essential
of a physical examination, and shaking hands is a in all situations. Loss of poise, lack of self-
common way to make contact when an educator control, and undignified behavior cause serious
first meets a person with asthma. In other situa- loss of face.
tions, despite recognizing the importance of
touch as a way of showing empathy, great caution Use words with care Language can be both a
is needed. As a general rule, the HCP should means of communication and a source of confu-
avoid touching them unless invited to do so. Latin sion. The asthma educator must be careful not to
Americans see touch as a sign of caring and assume that the person is familiar with the lan-
friendliness and a blessing. Mexicans see touch guage being used. Subtle nuances and word
as effective in preventing illness [11] that can be meanings may be difficult for someone to whom
caused by the evil eye. HCPs are expected to English is a second language. Remember too that
touch children. Asians, particularly Japanese and English changes from country to country. In
410 11 Adherence
England (home of the language), North American ready availability. However, this is often not a
“sidewalk” becomes a “pavement.” Hence, use good solution as their use leads to new prob-
simple, direct language. For those individuals for lems. For example, they may add their own
whom English is a new or second language, comments to those of the individual but make it
“Take a chair” or “Have a seat” can be quite con- appear as though the person uttered them. A
fusing; better by far to say “Please sit down.” nonfamily member may be more objective.
When using any interpreter, ask the interpreter
Some phrases change meanings in different what was said to the person with asthma. This
countries. For instance, the expression “to knock form of checking also ensures that the inter-
someone up” has nothing to do with pregnancy preter correctly understands and translates what
(as it does in the USA), but rather, it means to was said.
wake up a person (by knocking on their door). In some cultures, an up-and-down head move-
Similarly, the word “fix” in the Philippines means ment (a nod) does not mean yes; similarly, a side-
either a bribe, or a payment for services rendered. to-side movement does not indicate a negative or
Using the word “fix” implies a need for payment. no. Some individuals may nod their heads to indi-
Even the word “yes” can have different mean- cate that they are listening though they may not
ings. In the Philippines, it can mean: understand what is being said. It is essential to
check on their level of understanding by request-
• Yes ing them to explain in their own words what was
• If it pleases you just said.
• I am not sure Where possible, provide asthma materials in
• Maybe the language and at the literacy level of the per-
son. Highlight key points in the printed informa-
Yet when some immigrants say no, it may tion. Be aware that they may use terms in a
mean something quite different. Often the words nonmedical way that contradicts the medical
“no thanks” actually mean “Do you really mean usage of the same term. For instance, they will
that? If so, ask me again.” This generally applies speak of feeling depressed or being in shock but
to social invitations that are declined with a “no will not be using the words depression and shock
thanks” because the person being invited thinks in the medical sense.
the invitation is being made only out of
politeness. Make no assumptions Ask inviting questions
It is considered unmannerly and socially inap- such as “Tell me about your asthma.” Open-
propriate to disagree with someone, and ended questions will allow them to give more
insistence upon an answer can result in conflict. information than a question that requires a simple
Hence, the asthma educator must watch for both yes or no. The asthma educator should ask ques-
verbal and nonverbal hints and signals. tions to check personal understanding of the
Individuals who are not fluent in English may answers provided, so that what was said is not
be shy about communicating and prefer not to misinterpreted and that the person does not make
express themselves. Language then becomes a incorrect inferences.
barrier. Children of parents with limited English
proficiency were found to have almost triple the Be courteous The HCP should not interrupt
odds of having fair/poor health status [148]. They when the individual is talking. An interruption
were also five times as likely not to be brought in may break the flow of thought, and potentially
for needed medical care. important information may be lost if they feel
If there is difficulty in communicating, an that the interruption was intended to cut off fur-
interpreter skilled in medical and cultural issues ther discussion. Interrupting a person who is
should be used. Family members are thought to speaking is also considered a sign of rudeness in
be helpful and are often used because of their most cultures.
Be aware of beliefs Some individual beliefs part. Should welts be seen on fingers, the HCP
may be alien to the asthma educator’s way of should ask the person about them and then
thinking. For instance, some people from Asia, explain that the prescribed medication will have
Africa, and even the Caribbean believe that they the same effect—it will draw the tightness or ill-
are ill because evil can be (or has been) wished ness out of the body.
on them or their children. People, particularly Many people of Hispanic or Latin origin
from the Philippines, India, Pakistan, Malaysia, believe that diseases can be classified as hot or
Mexico, Sri Lanka, Cyprus, Turkey, Latin cold. A hot disease must be treated with cold
America, and areas around the Mediterranean, remedies and a cold disease (such as asthma)
believe in the “evil eye.” Instead of dismissing with hot remedies. Such individuals should be
their ideas and beliefs as improbable, the educa- encouraged to drink a hot beverage when taking
tor should attempt to find out how to work within medication. It is essential to be aware of their
these beliefs. For example, there may be some- thinking and incorporate it in some manner into
one in the ethnic group who is reputed to have the the treatment regimen. Resistance to or minimi-
ability to remove such evil wishes, and it may, in zation of traditional beliefs will result in an
the interests of helping an individual get better, antagonized individual. It is more effective to
be necessary to enlist this person’s help. The edu- meld new asthma information with preexisting
cator may have to explain to the individual that beliefs in order to gain their trust and willingness
while the ethnic healer works on removing the to cooperate.
evil wishes, the medication prescribed will help
them get better. Avoid gestures In many Eastern cultures, the left
hand is considered unclean. Hence, only the right
Some Spanish Americans believe that air or hand should be used when receiving or giving
bad air causes illness [144]. Some Hispanics something. Many cultures interpret gestures very
believe that evil spirits cause illness. African differently. Gestures involving the thumb or a
Americans see illness as retribution for sins com- ring formed with the thumb and first finger are
mitted and believe that faith in the healing power considered sexual and vulgar. Again, a gesture
of God will cure them. On the other hand, some such as tapping the temple can be a cause of
of them see illness as the result of witchcraft and misunderstanding.
resort to the practice of voodoo as curative [147].
Some believe in the theory of balance, in which In most Western cultures, the simple gesture
every birth requires a corresponding death, and of an outward-facing palm is interpreted as a
where illness is counteracted by recovery, but not request to stop. In the Middle East, this is a sign
necessarily of the same person who is ill. The of argument and confrontation; to certain African
belief that illness results from disharmony and cultures, it is the worst form of insult that can be
dissension in one’s own life is also prevalent. For made.
native Americans, who believe in the unity of
body and mind and in living in harmony with Involve the family In most cultures, the family
nature, illness comes from a discordance with unit is not restricted to the nuclear family but will
nature. It is essential to note that the same beliefs include both immediate and extended family
are not held by every person and that beliefs can members ranging from grandparents to cousins.
vary between groups within one ethnic commu- For many of these families, family members pro-
nity. Individuals’ beliefs cannot be categorized vide health information, and health problems are
by their ethnic origin. discussed with some, any, or all members of the
Many Asians believe in a form of healing family. The HCP should encourage other family
known as coin rubbing, whereby the illness is members to help put together, and be part of, the
drawn to the body’s surface through the welts asthma control program. There may be persons
that result from rubbing a coin on the affected within the family who provide advice that con-
412 11 Adherence
flicts with the HCP’s treatment plans, and such the family feels comfortable with them. Where
persons have to be gently neutralized. With possible, having a team member of the same cul-
Spanish-speaking parents, it is helpful to educate ture may generally be of considerable advantage
the children and encourage them to share their when dealing with these individuals. (It can also
knowledge with their parents [149]. This uses the be a disadvantage.)
strong lines of familial communication that exist Interracial marriages can bring richness to a
within Hispanic families. Even here, however, relationship but may also be a cause of possible
tact and common sense are needed. For example, conflicts. An awareness of these possibilities will
if a woman has premenstrual exacerbations, it is help the educator.
unlikely that a child would be a good medium
through which to pass appropriate information to Be alert for discrimination While every effort
such a person. can be made to not discriminate in any way
against the person with asthma, reverse discrimi-
A study involving 40 urban parents, who nation is also a possibility, since people retain
described their racial background as black, iden- their biases. For example, North American indig-
tified the most frequent barriers to asthma man- enous people may instinctively distrust non-
agement and care of their children as [150]: aboriginal medical personnel.
• Individual or family characteristics (43%)

• Environment (28%) Be aware of other issues One must not be over-
• Healthcare provider (18%) sensitive yet must be sensitive to issues that can
• Healthcare system (11%) arise from mixed marriages and generational dif-
ferences. There are also the problems that arise
The family’s culture [151] will dictate the with expectations and the roles both gender and
treatment and handling of the sick individual. In age play in those same expectations. Consider the
some cultures, once symptoms abate, the person following:
will no longer be treated as ill but will be expected
to return to the full level of participation exhib-
ited prior to the illness. Thus, the chronicity of • The person’s independence as well as their
asthma will be difficult for some cultures to com- interdependence on both the immediate fam-
prehend, and there may be considerable ily and the social context within which they
reluctance, if not resistance, to making allow- reside.
ances for the sick individual. • Whether they will actively try to achieve con-
Families will often present a strong united trol or remain passive.
front to an outsider. Until they accept the HCP as • Whether they prefer the authoritarian approach
a trustworthy person, they may not divulge or to be treated as a team member.
important information pertaining to the dynamics • Whether they prefer the open and expressive
of the family. This is true for many cultures, rang- form of communication or the formal and
ing from Asians to Hispanics and Native restrained mode.
Americans. Reticence is the watchword with • What life stresses affect them and what impact
many ethnic groups who do not favor the Western the illness has on personal life. Many individ-
approach of speaking out and being assertive uals tolerate ill health because they do not
[118]. Nor will they be open and willing to share know that the state of their health can be
personal information. improved considerably and noticeably.
In many cultures, divorce and marital separa-
tion are frowned upon and not discussed in pub- Many of the above remarks are valid for recent
lic. There may be many other family situations to and first-generation immigrants. They may or
which the asthma educator will not be privy until may not apply to the second and third genera-
tions. Different ethnic groups integrate into the • Is English a second or third (or possibly even
culture of the country at different rates but some a fourth language) for them?
form of integration will take place with each suc- • Do they speak English fluently? How well do
cessive generation. Often second-generation they understand spoken English? Where did
immigrants may denigrate the use of old ways in they learn English? Do they read English? If
favor of Western, scientific medicine. They may so, at what level?
be reluctant to allow their elders to use traditional • What is their religion?
methods. This can be a source of conflict within • Do they associate only with persons belonging
the family. to a specific ethnic and cultural group?
Many cultures and religions have strong, • In what kind of neighborhood do they live? Is
active community groups that can help by pro- it composed of people of the same culture and
viding translators and information pertaining to ethnic origin? Is it homogeneous with respect
their distinctive and different practices. This to religion and culture?
should be taken into account when providing • Is the person a first- or second-generation
asthma education. Often volunteers can be immigrant?
recruited from community groups or churches • Do they continue to wear the traditional cloth-
to assist in the preparation and evaluation of ing of the country of origin?
educational materials. Further aid can be pro- • Are dietary habits from the country of origin
vided by preparing a list of physicians who maintained?
work well with persons of different religious • What sort of traditional medical treatment do
and ethnic origins. they use or prefer to use?
Politeness and courtesy should be the watch- • Are they and their ethnic neighbors isolated
words when dealing with individuals of differ- from the rest of the city, living in the equiva-
ent cultures and different religions. Tone of lent of an ethnic ghetto?
voice, gestures, attitude, and body language • Is there racial discrimination against this par-
speak volumes. An open mind and understand- ticular ethnic group?
ing attitude will go a long way to further rela- • How does the person react to Western
tionships with them. They will be forgiving if culture?
one explains that one does not know enough • What is the family’s approach to the current
about their culture and does not wish to give personal medical crisis?
offence. In fact, they will most likely be eager to
talk about their culture if one shows a degree of Some of the above questions can be answered
interest. without actually being asked, by a face-to-face
There are certain questions to which answers meeting.
should be obtained, so that the educator can It is important to remember that different cul-
understand their background [136, 143]. These tures have different approaches to birth, sexual-
include: ity, childbirth, illness, and death. Any questions
asked must be framed in a careful manner, deliv-
• Is the person a recent immigrant? ered respectfully, and interpreted in context.
• Which country did the person come from Assumptions should not be made [151].
originally? Many immigrant groups are becoming more
• Is the person a refugee? If so, was their coun- Americanized and taking on the same values held
try in the grip of war? by the majority of Americans while retaining
• How long have they been in this country? their diversity of language, heritage, customs,
• Which country or countries did they traverse and culture. HCPs need to recognize the changes
before coming here? that must be made to meet the health needs of
• Were they coming from an urban or rural area? different cultural and ethnic groups.
• How “different” is their culture? In summary, the simplest approach requires:
414 11 Adherence
• An open, caring, understanding, and nonjudg- 4. Review the pulmonary function test provided
mental attitude in Chap. 3. What questions and action should
• A formal and polite manner of behavior you take for this person?
• Speech that is simple, clear, and precise
In addition, the setting of the consultation References

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Complementary and Alternative
Medicine in Asthma
12
Contents
12.2 Specific Types of Care 426
12.2.1 Relaxation 427
12.2.2 Meditation 427
12.2.3 Yoga 427
12.2.4 Biofeedback 427
12.2.5 Breathing Exercises 428
12.2.6 Hypnosis 428
12.2.7 Imagery 428
12.2.8 Therapeutic Touch 428
12.2.9 Religion 429
12.3 Professions 429
12.3.1 Osteopathy 429
12.3.2 Chiropractic 429
12.3.3 Acupuncture 431
12.3.4 Homeopathy 432
12.3.5 Massage Therapy 433
12.3.6 Naturopathy 433
12.4 Self-Help CAM 434
12.4.1 Herbs 434
12.4.2 Nutrition and Nutritional Supplements 436
12.4.3 Exercise as Treatment 437
12.4.4 Electromagnetic Treatment 438
12.4.5 Aromatherapy 438
12.4.6 Reflexology 438
12.5 Approach of the Educator 438
References 440
422 12 Complementary and Alternative Medicine in Asthma
practors or naturopaths. The controversy exists

Key Points throughout the range of human disease and dis-
• Complementary and alternate medicine comfort and applies to asthma and allergies as
(CAM) approaches are often popular much as to any other condition. In the past, physi-
with those with any chronic condition, cians—both individually and via their professional
including asthma. organizations—opposed such unconventional
• This chapter discusses the specific types care. It is confusing; to take one example, relax-
of care including relaxation, meditation, ation is seen as an alternative therapy. There are
yoga, biofeedback, breathing exercises, many similar examples of confusion about what is
hypnosis, imagery, therapeutic touch, and what is not an “alternative” therapy or
and religion. approach. Paradoxically, this increase in alterna-
• CAM professions include osteopathy, tive approaches comes at a time when medicine,
chiropractic, acupuncture, homeopathy, more than ever, is committed to evidence-based
massage therapy, and naturopathy. care. Despite this, the boundaries are blurred. Now
• CAM modalities are often used on the many “conventional” practitioners, including a
sole initiative of the person with asthma: wide range of healthcare providers such as physi-
–– Examples are herbs, nutritional sup- cians, nurses, and pharmacists, also practice some
plements, exercise as treatment, elec- form of alternative medicine in addition to offering
tromagnetic treatment, aromatherapy, conventional care.
and reflexology.
• The asthma educator needs to be aware
of the CAM modalities, how to approach
individuals who use them, and how to Points to Ponder
discuss them knowledgeably. Alternate therapies have a long tradition
and are the primary form of treatment in
many cultures.
Decades (or centuries) of use is not by
itself proof of benefit.
Chapter Objectives
able to:
Most conventional practitioners now recog-
1. List some of the complementary and nize that competent adults, not healthcare profes-
alternate modalities of treatment used sionals, have the right and the authority to make
by persons with asthma and allergies. choices about their own care. And the reality is
2. Explain the concept of integrative that these competent adults, also known as ordi-
medicine. nary people, include components of alternative
3. Discuss the use of alternate therapies practice in their healthcare while still following
and their dangers. some of the advice and prescriptions provided by
their conventional practitioner. They do not nec-
essarily see why they should not use conventional
medicine and alternative practices or medicines
12.1 Introduction at the same time and find polarized positions on
this issue distressing. They wish to use what they
The use of self-help and “natural” substances, consider the best of both conventional medicine
such as herbs, despite being extremely common, and alternative practice. Thus, they see the alter-
has been and remains a very controversial topic. native options as complementary to conventional
So too is seeking the advice of, for example, chiro- medicine.
The term “complementary” has come to in some cultures, are the primary forms of treat-
encompass a wide range of “unconventional” ment. Some forms of treatment are only available
treatments. To further avoid dealing with the con- in a specific part of the world. For example, the
troversy, the term complementary/alternative treatment of asthma in caves or salt mines (spe-
medicine (CAM) is now used, and it neatly skirts leotherapy) is only available (and used) in Eastern
the issue of whether a specific treatment is really Europe [7]. Spas are used for asthma in Europe
alternative or whether it is complementary. This and Japan and may produce benefit.
chapter will provide information to educators on Finding a clear, concise, and acceptable defi-
the use of CAM modalities, a detailed description nition of CAM has been nearly impossible
of some of those in use, and advice on how they because of the many different modalities of treat-
can cooperate with individuals over this issue. ment, some of which have already been listed.
One of the contentious issues is the assess- The most widespread definition, “medical inter-
ment of evidence, but CAM adherents and practi- ventions that are not taught at conventional medi-
tioners are not alone in recommending treatments cal schools, nor available in hospitals,” is
on inadequate evidence. High aims are not always obviously limited and becomes increasingly
followed, and Chap. 6, in the section on Treatment untrue with the passage of time and with changes
Options, makes reference to the fact that many in perception of CAM and conventional medi-
licensed medicines are used in asthma without cine. While this definition is useful as a working
strong or, in some cases, any evidence of benefit. definition, there are three objections to it. The
Pharmacy stores, part of the conventional health- first two are obvious: CAM is taught in some
care system, stock self-treatment medicines, and medical schools and there is a considerable over-
for some of these, such as common cough medi- lap between what is considered CAM and what is
cines, there is no evidence of benefit [1]. considered conventional in terms of nutritional
The cost of CAM is extensive, and in 1990 it approach, use of exercise and prayer, and use of
was suggested that $13.7 billion was paid for relaxation techniques, although there will be dis-
CAM products in the USA [2]. In a more recent agreement on the details. The third qualification
study [3], it was conservatively estimated that relates to the empirical scientific nature of con-
$21.2 billion was paid for CAM professional ser- ventional medicine. In other words, if appropri-
vices in 1997, and the total out-of-pocket expen- ate evidence shows a CAM modality to be
ditures for CAM were conservatively estimated successful, it will become accepted and incorpo-
at $27 billion. This is comparable to the out-of- rated within conventional medicine, and no lon-
pocket expenditure for all US physicians’ ser- ger be CAM.
vices. By 2007 adults in the USA had spent $33.9 In a recent review of courses involving CAM
billion on CAM [4]. at US medical schools, 51% offer elective courses
A study [5] published in 2016 found that one in CAM or include the topics in required courses.
in five individuals in the USA used CAM with There were 127 courses reported, with almost a
adults spending $28.3 billion and costs for chil- third of US medical schools having CAM as part
dren $1.9 billion for a total of $30.2 billion. The of required courses. The educational format
researchers noted that increased spending on included lectures, demonstrations by practitio-
CAM was related to family income. ners, or presentation by users; and the topics
Many different modalities of care are included included chiropractic, acupuncture, homeopathy,
under the general rubric of CAM. The most com- herbal therapies, and mind-body techniques [8].
monly used are breathing exercises, homeopathy, Healthcare providers not only incorporate
herbal care, and acupuncture [6]. Others include CAM in their practice, but many also refer indi-
folk medicine, special diets, faith healing, new viduals under their care to other practitioners. In
age healing, chiropractic, naturopathy therapy, a review of 25 surveys between 1982 and 1995, it
massage therapy, music therapy, yoga, and so on. was found that physician referrals were highest
Many of the therapies have a long tradition and, for acupuncture (45%), but it also included chiro-
practic (40%) and massage (21%) [9]. Some One in four did not currently use prescription
CAM practitioners use chiropractic, massage medicine, and about the same number used herbal
therapy, and homeopathy on the same individual. remedies; 18% used caffeine treatment, and 22%
Of the surveyed physicians, varying numbers used other alternate therapies.
believed in the efficacy of different treatments, The widespread use of CAM has led to educa-
including 53% who believed in the efficacy of tional materials being available for the use of spe-
chiropractic, 51% in acupuncture, and 48% in cialists in allergy and asthma, and these are useful
massage but only 26% in homeopathy and 13% references for the educators too [14, 15]. In a sur-
in herbal approaches. vey of CAM organizations, it was stated that the
The widespread use of CAM has been recog- most frequently used therapies for respiratory
nized for more than a decade. One in three problems and asthma included aromatherapy,
Americans, one in two Australians, and one in Bowen technique, homeopathy, magnetic ther-
four Britishers use CAM [6, 10]. The use appears apy, massage, and reflexology [16].
to be increasing, although some of the results are Reasons for the use of alternative medicine
conflicting. Eisenberg and others [3], authors of have also been explored [17]. In one study, three
one of the original studies, carried out further hypotheses were tested: CAM was used because
random household telephone surveys comparing of dissatisfaction with conventional treatment or
the use of CAM between 1990 and 1997. In 1997 that alternative treatments were perceived as
they reported that 42.1% of those surveyed used offering more personal autonomy and control
at least one of the sixteen CAM listed, and the over healthcare decisions or thirdly, the alterna-
probability of users visiting a CAM practitioner tives were seen as more compatible with personal
was about 46.3%. Only 38.5% of these individu- values and worldview of beliefs about illness.
als in 1997 disclosed the use of CAM to their There were 1035 individuals randomly selected
healthcare providers, similar to the finding in the from mail surveys, and most CAM users appeared
previous study. However, in the National Health to select these treatments mainly because they
Interview Survey of the USA [11] that looked at found the healthcare alternatives more congruent
12 types of CAM use over the previous year, the with their own values, beliefs, and philosophical
results were different. A smaller number, but still orientation toward health and life. They were less
substantial, of 28.9% of US adults used at least likely to do so as a result of being dissatisfied
one CAM therapy in the previous year. The three with conventional medicine. The study further
commonest were spiritual healing or prayer showed that only 4.4% of those studied used
(13.7%), herbal medicine (9.6%), and chiroprac- CAM as their primary source of healthcare
tic (7.6%). The Centers for Disease Control and advice. CAM users were also well educated.
Prevention’s National Health Interview Survey Factors listed in another article for use of CAM
issued a news release on May 27, 2005, that include:
stated that, as of 2002, over 36% of Americans
used CAM [12]. • Frustration with the limitations of conven-
CAM is extensively used by persons with tional medicine
asthma and allergies. Conventional care does not • A sense that conventional medicine treats
provide a cure, and these conditions may be life- individuals like machines
threatening. They also affect lifestyle, and control • An awareness of medical practice from differ-
measures suggested by healthcare practitioners ent cultures
and educators require discipline in avoiding envi- • Scientific evidence linking disease to nutri-
ronmental agents and in regular use of prescribed tional, emotional, and lifestyle factors
medications. Some of these reasons may influ- • A desire for wellness rather than absence of
ence the use of alternative medicine. For example, disease
a study in California [13] found extensive use in • A desire to reduce medication and their conse-
300 individuals with asthma or rhinosinusitis. quent potential negative side effects
• A desire to reduce personal costs Despite the acceptability of CAM, it is very

• Support for CAM by some healthcare provid- difficult to evaluate these therapies in a way that
ers [18] is acceptable to practitioners and individuals
seeking treatment [21]. Modern conventional
Many users of CAM, and many CAM practi- medicine encourages practices that are evidence
tioners, seem to be enthusiastic proponents of the based and is moving toward a personalized
World Health Organization’s definition of health approach, that of precision health. But change is
as “a state of complete physical, mental, and slow, and much of what healthcare providers do
social well being and not simply the absence of today however is not evidence based, either
disease or infirmity” [19]. Some go further and because the practice precedes the modern scien-
claim that adherence to this definition is a distin- tific area of medicine or because the evidence
guishing feature between CAM practitioners and available does not fit the specific circumstances
conventional healthcare systems, thereby imply- of the person being dealt with. Nevertheless, the
ing that conventional healthcare systems and randomized controlled trial is still regarded as the
practitioners are not interested in the whole per- best method for collecting evidence. In this, treat-
son. Those who use CAM see considerable ben- ments are compared to one another in controlled
efits in achieving a greater degree of control over circumstances, possibly with a placebo included,
their own healthcare choices and, perhaps, also and are evaluated in such a way that none of those
improving their health and reducing side effects. participating in the study are aware of the type of
There are however some risks to CAM, which treatment they are receiving. CAM is now mov-
should be noted by educators. The most obvious ing in this direction but still relies very heavily on
risk is that users will not take lifesaving medica- individual stories recounting success, so-called
tion, such as inhaled corticosteroids for severe anecdotal evidence.
asthma, because of fear of side effects. There is On a personal level, if people feel better after
also the risk that they may well find it easier to a CAM consultation, or after using a CAM rem-
take CAM than follow the detailed environmen- edy, it is understandable that they will have posi-
tal advice given by professionals and educators. tive feelings toward that practitioner or remedy. It
There are also potential harms with some CAM- is understandable also if they continue with
related diets, specifically those which are very CAM. Unfortunately, one person’s experience
restrictive and do not provide a full nutritionally cannot be used to distinguish cause and effect
balanced intake of food. from the natural variability that occurs with all
Some herbal or traditional medicines are not diseases, particularly with asthma and allergies.
standardized, and some contain potent medica- Thus, using stories to make specific treatment
tions or substances that can cause harm. For recommendations to a large group of people is
example, of 120 samples of alternative medicine considerably different from making that recom-
prescribed by Ayurvedic or homeopathy practi- mendation based on empirical evidence. It is
tioners for conditions such as asthma, 38.32% noteworthy that, in a study related to physicians’
contained corticosteroids. The authors speculated attitudes toward such treatments as acupuncture
that the lack of proper quality control mecha- or chiropractic, the word used was “belief” rather
nisms was a factor but pointed out that these than “accept the evidence for” [9].
“alternative medicines” could cause adverse A number of alternative practices are very
health effects and also bring alternative medicine dubious, and some of these are seen in the book-
into disrepute [20]. The FDA investigated the shelves and magazine racks of any bookstore and
safety of ephedra in dietary supplements and promoted on the Internet. An example might be a
issued a consumer alert on the safety of dietary system of healing which applies to all disorders
supplements containing the product, with the and is heavily promoted by a particular author,
intention of prohibiting the sale of such supple- who may or may not have a medical degree. Such
ments (FDA News Release December 2003). remedies are seen as universal care and do not
bring credit to the CAM practitioner or to CAM allude to those whose usage is prevalent and/or
as a whole. Fortunately, these are probably not seem to offer particular advantages. They have
the norm, and most CAM practitioners are sin- been divided into three major groups:
cere in their efforts.
So far, only the relationship between CAM • The whole series of therapies involving mind-
and conventional medicine has been discussed, body interaction, including relaxation, medi-
but a new idea, that of integrative care, is gaining tation, biofeedback, hypnosis, guided imagery,
ground. It is too soon to say whether or not it will spirituality, and therapeutic touch.
be successful in the long run. Integrative care • Specific healthcare professions, such as chiro-
refers to the incorporation of CAM practices and practic, acupuncture, homeopathy, massage
practitioners in regimens used by conventional therapy, and naturopathic healing.
healthcare organizations. A specific instance of • The very popular self-help modalities now in
this was reported from the Center for Holistic increasing use include herbs, exercise, electro-
Pediatric Education and Research in 2001 [22]. magnetic therapy, aromatherapy, nutritional
This referred to holistic medicine consultations therapy with vitamins and minerals, and
in a teaching hospital, noting that 43 of the 70 reflexology.
consultations were for oncology and generally to
help manage symptoms, such as nausea, pain, Mind-body therapies are increasingly com-
insomnia, or agitation. They also dealt with mon, and some are difficult to distinguish from
questions about herbs, dietary supplements,
psychological techniques used by conventional
mind-body therapies, and massage. medicine. Many conventional practitioners—
Bell et al. [23] define the term “integrative such as those in psychology, trained counselors,
medicine” in detail. In their view this is not healthcare providers, or nurses—will not accept
merely adding CAM to conventional medicine, all of the assertions of the “mind-body” move-
but it “represents a higher order system or sys- ment nor that these are relevant to every
tems of care that emphasize wellness and healing individual-professional interaction. Nevertheless,
of the entire person as primary goals, drawing on some mind-body therapies appear to be effective.
both conventional and CAM approaches.” A word of caution is needed, as sometimes the
Outcomes from integrative care will need to reports do not list clear criteria for the diagnosis
move beyond examining parts of healthcare and of asthma. It may be that the treatment really
focusing on portions of the individual’s body and deals with someone with asthma or one of its
will need to look at the whole. The “whole sys- coexisting conditions, such as anxiety. In a fam-
tem” method of intervention, as described by ily medicine study, Thomas [24] demonstrated
Bell et al., would include the individual-provider that 29% of those diagnosed with asthma in a
relationship, multiple conventional and CAM general practice had evidence of dysfunctional
treatments, and the philosophical context of care. breathing. Many of them may have had both
However, whatever word is used, whether inte- asthma and dysfunctional breathing, and some,
grative or something else, the clash between sto- dysfunctional breathing without asthma. Despite
ries and evidence will remain. No matter the that caveat, there are many good reasons and
underlying beliefs of those being helped, the edu- explanations for a connection between therapies
cator should maintain a respectful approach. directed at mental activity and asthma.
It has long been observed that stress is a nega-
tive factor in individuals with asthma, as with
12.2 Specific Types of Care other chronic diseases, and methods designed to
alleviate stress may well be helpful. More recently
There are many different CAM treatment, tech- a connection has been noted between various neu-
niques, and professions, as indicated earlier. Not ropeptides in the lung such as substance P, neu-
all will be dealt with here; rather, this section will rotransmitters in the autonomic nervous system,
12.2 Specific Types of Care 427
and various cytokines acting as immunomodula- experience progressively higher levels of thought,
tors. There is thus a plausible mechanism for until pure consciousness is experienced.
brain functions to affect the immune system both Some effects of meditation have been demon-
negatively and positively. Even without consider- strated, including:
ing specific CAM treatments, simple events such
as music, laughter, group support, and keeping a • Reduction in oxygen consumption
diary about life events may all be factors which • Reduction in heart and respiratory rate
can reduce stress and, perhaps, have an indirect • Specific effects on electroencephalograms
effect on the immune system. • An effect on hormones implicated in stress,
such as production of cortisol
12.2.1 Relaxation There is some disagreement as to whether

meditation always produces these physiological
This would seem to be good for anyone, whether changes. As with relaxation therapy, developing
or not they have asthma! Specific relaxation ther- the ability to meditate at deeper or higher levels
apy goes back to the early years of the last century requires a major commitment of time. Meditation
[25], with the earliest being progressive relaxation may be one way to help with increased stress.
therapy started by Jacobson in 1905 and further
developed over the years. Some components of
Jacobson’s methods include a focus on tense mus- 12.2.3 Yoga
cles, using mental thoughts to relax the tension,
and observing the difference in the muscle pre- A 2013 Cochrane review of 13 studies involving
and post-relaxation. This is applied to all major 906 adults with mild to moderate asthma found no
muscle groups. People using this technique evidence to support the efficacy of yoga in its
become aware of the slightest evidence of tension treatment. A 2014 systematic review and meta-
and develop the skills to reduce that tension. analysis of randomized controlled trials that
There have been many recent developments in involved 824 adults with asthma also found no
relaxation. During the initial instruction in relax- evidence that yoga as an intervention was helpful
ation therapy, the individual learns tension and [27]. The reviewers suggested that while yoga
release techniques with different muscle groups and could not be considered a routine intervention, it
moves on through each session to increase the num- should be regarded as an “ancillary intervention
ber of muscle groups involved. Some evidence or alternate to breathing exercise for asthma
exists that relaxation therapy may act through the patients.” The authors of the 2013 Cochrane
autonomic nervous system and produce specific review repeated their research 3 years later and
helpful responses. This has been observed in its found some moderate evidence that yoga “proba-
effect on cardiovascular activity and the heart rate. bly” leads to improvements in both symptoms and
However, a recent systematic review [26] concluded quality of life in individuals with asthma [28]. As
that a lack of evidence of efficacy of these therapies is almost invariable in reviews of the evidence for
in asthma was due to poor research methodology. a CAM modality, the suggestion is “further stud-
ies.” Yoga is a very common activity that many,
with and without asthma, find enjoyable.
12.2.2 Meditation
Meditation has been in existence for thousands of 12.2.4 Biofeedback

years and includes such well-known practices as
yoga [25]. It has been studied in detail for over Biofeedback teaches individuals to regulate their
25 years. Variations exist, including transcenden- physiological functions [25]. Usually some
tal meditation, in which the mind is thought to objective measure, such as skin temperature or
EMG (electromyogram), is used during the Many studies have been done on hypnosis and
teaching process. An analogy of this might be the asthma, but most either did not have a control
dancers’ use of mirrors to observe themselves as group or did not have any objective measure-
they learn various movements. ments. However, in a study with good control
The primary goal of biofeedback is to give groups and good measurements, Ewer and Stewart
control to the individual. Some of the underlying [34] showed that individuals who used hypnosis
ideas that led to its development came from the had a decrease in bronchial hyperresponsiveness
idea that stress is a critical factor in disease. measured with methacholine. There is thus some
While individual practitioners may use biofeed- evidence that hypnosis may help asthma. In a
back to treat asthma, and the stress associated review of the literature, it was concluded that
with it, this has not been a major feature of the studies had demonstrated an effect of hypnosis
literature in biofeedback. Biofeedback has how- but that larger, controlled studies were needed.
ever been shown to help relieve tension, migraine Hypnosis seemed to be best when subjects were
headaches, and temporomandibular jaw pain. susceptible, the investigators were experienced,
and several sessions and autohypnosis were con-
ducted [35]. Suppressing recognition of symp-
12.2.5 Breathing Exercises toms in asthma can be dangerous, and the educator
must bear this in mind when discussing hypnosis
These are probably a subdivision of biofeedback, with individuals with asthma.
and conventional psychologists use some of
them. One, thought to be specific for asthma, is
the Buteyko technique, which is based on the 12.2.7 Imagery
belief that asthma is due to a low level of carbon
dioxide (CO2). Two studies were done, one of Invoking and using the senses, imagery is incor-
which showed a reduction in inhaled corticoste- porated into some of those treatments already
roid use without any improvement in FEV1 [29], described. Personal images are believed to pro-
while the other showed an improvement in qual- duce physiological, biochemical, and immuno-
ity of life [30]. A recent review found some posi- logical changes that, in turn, produce beneficial
tive effects of breathing exercises on lung health outcomes. One of the mechanisms of
function, hyperventilation symptoms, and quality imagery that might be helpful is that of “mental
of life [31]. Again, all suggested further studies. rehearsal.” An individual may consider how she
Overall, reviews of breathing techniques con- or he might respond to an episode of acute asthma
clude that there is insufficient evidence to draw and use imagery, in advance, to help rehearse
firm conclusions about their efficacy [32, 33]. appropriate coping skills. Imagery will be suc-
cessful if the person is interested in this method
and believes that mind-body effects can be altered
12.2.6 Hypnosis through its use. However, when imagery is used,
memories and emotions sometimes surface that
A very old procedure, hypnosis allows the mind cause distress, and therefore, imagery should best
to affect the body [25]. It was developed in the be used by skilled healthcare professionals.
eighteenth century by Mesmer and is now used
by many CAM practitioners. It is also a treatment
used by many psychiatrists and psychologists 12.2.8 Therapeutic Touch
within the conventional system. Client motiva-
tion is required for hypnosis, and there is suspen- This depends on the belief that energy fields sur-
sion of some peripheral awareness and a state of round the body and can be manipulated to good
attentive-focused concentration. Hypnosis has effect. The presence of these fields has never
been successfully used in many medical situa- been demonstrated, but there is a strong move-
tions, including surgery and severe pain. ment of support for therapeutic touch. It is
thought that the practitioner directs energy 12.3 Professions

toward the person. Therapeutic touch has been
used with almost any condition and would seem 12.3.1 Osteopathy
to be safe. There is always the caveat, however,
that the use of an ineffective therapy as an alter- Osteopathy was founded by Dr. Andrew Still as a
native to conventional therapy can be dangerous, manipulation practice. A school of osteopathy
particularly in those individuals with more severe was opened in 1892 [25]. This profession grew,
asthma. A formal test of therapeutic touch showed and indeed by 1968 it began to amalgamate with
that practitioners were unable to detect the inves- medicine. Osteopathy now describes itself as a
tigator’s “energy field.” The investigator con- “branch of mainstream medicine” [37]. Today,
cluded that this was “irrefutable evidence that the differences in practice between those with a DO
claims of therapeutic touch are groundless and degree are only marginally different from those
that further professional use is unjustified” [36]. with an MD [38]. In addition, in most US states
today, persons with the qualification DO (doctor
of osteopathy) are licensed medical practitioners,
12.2.9 Religion who may prescribe controlled substances and
order any diagnostic test.
Religion is classified as a mind-body activity. It would seem that some osteopaths have
This is not to suggest that any one religion is “crossed over” or have “straddled the fence” and
better than any other but, rather, that religion is an are in both camps, and they have embraced mod-
important component of many people’s lives. ern medicine. Nonetheless, their profession has
Most people instinctively sense or believe in a maintained its separate identity through extensive
higher power. There have been a number of incon- training and use of manipulation. Osteopaths
clusive studies on whether prayer can help out- may take residency training and specialize, but
comes, and there is no objective way to demonstrate most are general practitioners. People with
benefit from prayer. Nonetheless, a lack of objec- asthma who consult an osteopath are likely to
tive proof does not minimize the importance of obtain conventional care and advice with, per-
religion in the life of society. If prayer brings sol- haps, manipulation as well.
ace to some, it should not be discouraged, since
mental health and peace of mind is as important as
physical well-being in bringing about improve- 12.3.2 Chiropractic
ment in the quality of life of a person.
To summarize the information on the various In terms of overall CAM, this is a very prominent
mind-body modalities used, some, such as reli- profession, with an estimated 70,000 practitio-
gion, perhaps should not be considered a CAM, ners in 2019 and earnings of over $6 billion per
while others such as therapeutic touch lack any year in the USA [39, 40]. Chiropractic was
objective evidence of benefits. Among the other founded by D.D. Palmer, who emigrated from
techniques, including relaxation, hypnosis, and Canada to the USA in the late nineteenth century.
so on, there may well be benefit, particularly to Originally a farmer and a grocer, he went on to
persons for whom stress is a part of the illness. become a magnetic healer. He had a flash of
When the educator discusses these modalities insight one day and gives an account of his first
with them, it should be with some knowledge of “patient” who was deaf. Palmer decided that the
the individuals themselves, their lives, the sever- deafness was due to a misplaced vertebra and
ity of their asthma, and their attitude to conven- “adjusted” the vertebra; the man’s hearing
tional treatment. A mental health practitioner improved. This took place in 1895, and by 1898
may more safely carry out many of the CAM he had accepted his first students and started
mind/body modalities of treatment, but this is not awarding the designation DC (doctor of chiro-
invariably true. practic). Early chiropractors were frequently
arrested and prosecuted for practicing medicine objective measurement. Nielsen et al. [42] stud-
without a license. ied 31 adults with asthma who were randomly
Chiropractic needs to be carefully distin- given active or sham chiropractic manipulations
guished from osteopathy in terms of current prac- twice weekly for 4 weeks. There were no clini-
tice, although they may not be that different in cally important differences between the chiro-
their origins. There was animosity between phy- practic and the sham treatment. A review
sicians and chiropractors in the early parts of the concluded that there is little evidence that chiro-
last century. In 1974 chiropractic was recognized practic should be used in asthma [43]. In
as a profession by all US state authorities. Partly Canada, the heads of the academic departments
as a defense against conventional medicine, it of pediatrics, following a detailed review of the
also developed its own language and claimed that literature, produced a joint statement that chiro-
it did not treat disease but, rather, that it “promoted practic should not be used in children for any
healing.” In a famous lawsuit, the US Supreme purpose [44].
Court in 1990 supported chiropractic against the In addition to the lack of evidence for chiro-
American Medical Association, as a result of practic helping asthma, there is the potential of
which the AMA had to cease its opposition of damage. One potential way in which damage
chiropractic. However, unlike osteopathy, chiro- can occur is by opposing vaccination, and this
practors cannot prescribe controlled substances can be dealt with by open discussion with the
and can order only a limited number of diagnos- individual and the chiropractic professional. A
tic tests. potential risk of chiropractic is stroke, particu-
The education of chiropractic practitioners larly when there is manipulation of the cervical
usually requires 2 years of undergraduate educa- spine [45]. Descriptions of stroke precipitated
tion and then 4 years at one of the sixteen US by chiropractic have been published in the med-
schools that are accredited by the American ical literature, but the chiropractic profession
Chiropractic Association. The underlying phi- disputes the conclusions, and this is an area that
losophy of chiropractic is that misaligned spinal is still under investigation [46]. A recent review
vertebrae lead to subluxation and nerve damage. was cautious in its conclusions. The article
It is believed that damage to nerves goes beyond pointed out, in regard to serious adverse events,
local issues such as back pain and may be a cause “gaps in the literature and inherent method-
of many systemic disorders. Therefore, there is a ological limitations of studies” [47]. There was
belief that spinal manipulation will correct many a recommendation that informed consent must
non-musculoskeletal disorders. include information on risks during the treat-
The chiropractic belief is that adjustment, ment process.
using either direct or indirect thrust to the spine, All healthcare practitioners, whether conven-
will correct the subluxation and lead to improve- tional or involved in CAM, should cooperate
ment in symptoms. Chiropractors may also use closely when treating individuals under their
X-rays to view the spine and will use thrust in care. A national random survey of 400 chiroprac-
combination with other modalities of treatment, tors and 400 family physicians found that family
such as ice, heat, and ultrasound. Many practitio- physicians received information from chiroprac-
ners will also offer advice on lifestyle, nutrition, tors on 26.5% of referrals, while chiropractors
and rehabilitation. received information from family physicians in
Historically chiropractic has been antagonistic 25% of cases [48]. Both groups believe that they
to vaccination. While this attitude is changing did not receive enough information on “adverse
today, there is still some evidence that students, outcomes of treatment plans for shared patients.”
during the course of their training, become less The reasons why individuals would receive care
favorably disposed to vaccination [41]. from both professions were not revealed, but it is
Some chiropractors believe their treatment is more likely to have been due to low back pain
helpful for asthma, but this is not supported by than to asthma.
12.3.3 Acupuncture individuals to symptoms rather than fundamental

improvement. In a systematic review of all of the
Acupuncture uses thin needles to stimulate spe- studies on acupuncture, it was concluded that
cific sites in the body and is thought to correct the claims for the benefits of acupuncture “are not
balance of Qi (vital energy) [23]. Qi (pronounced based on the results of well-performed clinical
chee) is believed to flow through pathways in the trials” [50]. Studies since then have endorsed this
body called meridians. There are 12,000 meridi- conclusion. In a randomized crossover double-
ans and between 365 and 2000 points, where acu- blind study of 23 adults with asthma, allocated to
pressure can be applied to achieve success. There “real” or “sham” acupuncture, no benefit was
is some evidence that these sites correspond to shown in any objective measure [51]. In a further
nerve endings and some evidence that the merid- study of 23 adults, again randomly assigned to
ians may correspond to lymphatic channels. “real” or “sham” acupuncture, detailed monitor-
Acupuncture was practiced in ancient China ing was carried out including FEV1, methacho-
and developed over thousands of years. Even in line challenge, peak flow variability, and an
China it had its opponents and, in the eighteenth asthma diary. There was no change in any of the
century, was banned by the Chinese emperor. The measures [52]. A newer technique, laser acu-
theory underlying the practice is that of yin and puncture, was also tried in a double-blind cross-
yang, the issue of contrasting features and fea- over study of 44 children and adolescents with
tures which change continuously. There are exercise-induced asthma [53]. Again no benefit
thought to be eight patterns affecting life forces was shown.
and three treasures: Shen, Jing, and Qi. Shen is The NIH Consensus Statement on Acupuncture
the spirit and the treasure that brings happiness; suggested its use in many disorders [54]. Those
Jing is the substance that underlies our physical participating were to give “scientific evidence ...
self and the basis of reproduction; and Qi is the precedence over clinical anecdotal experience.”
vital energy and is connected with the current or The preamble to the statement pointed, correctly,
present state of transformation in which the indi- that much of conventional medicine was not evi-
vidual exists. dence based. However, the authors did not take
The specific acupuncture points are between 1 the same action as the NIH Expert Panel Report
and 5 square millimeters in size and stimulated on asthma that tried to move medicine toward an
by specific needles. The literature supporting the increase in its evidence base [55]. The authors of
relief of pain by acupuncture is considerable. the asthma report were to “base the recommenda-
Acupuncture was popularized in North America tions on their review (of scientific literature) and
in 1971 when James Reston described in The to cite studies that support the recommenda-
New York Times [25] how, due to this treatment, tions.” They did so and their conclusions are
he had virtually no postoperative pain after his rightly influential. The acupuncture consensus
appendix had been removed. statement concluded that acupuncture was estab-
The effect of acupuncture in asthma has been lished in a number of conditions but not asthma.
the subject of many studies. It certainly seems to No evidence was cited on its use in asthma; nev-
reduce the sensation of breathlessness and has ertheless, the conclusion was that “acupuncture
also been shown to reduce bronchial hyperreac- treatment for many conditions such as asthma or
tivity [25]. In a prospective randomized single- addiction disorders should (sic) be part of a com-
blind study of the use of real and sham prehensive management program.”
acupuncture in exercise-induced asthma in 19 The educator is thus left in a quandary since a
children, no benefit was shown from real acu- prestigious body has suggested, without provid-
puncture [49]. In chronic asthma, the comparison ing evidence, that acupuncture be an integral part
of acupuncture with sham acupuncture has given of asthma management. In its examination of the
inconsistent results. There is apparent improve- available evidence, the Cochrane group concluded
ment, but this may simply be the desensitizing of there is a possibility that individuals with asthma
Hahnemann [25] developed homeopathy in

Germany. He studied a number of illnesses and
their treatment and postulated that if one could
identify something that caused a disease, diluted
it, and give the diluted substance to the ill person,
then a cure would be effected. He developed the
principle of similars, the principle of infinitesi-
mal dosage, and the principle of specificity of the
individual. The principle of similars states that if
a substance in a large dose induces disease symp-
toms, then a small dose will cure the disease. This
principle of similars has been compared with the
Fig. 12.1 Laser acupressure. This picture was taken in
Ukraine where many alternate forms of care are available, procedure involved in immunization or in desen-
particularly if equipment is involved. (© I Mitchell) sitizing to allergies. Dr. Hahnemann believed that
the more dilute the substance, the more effective
it became, which also meant that toxic effects
may benefit from acupuncture [56]. However, the could be avoided. Undoubtedly one of the rea-
data did not permit making recommendations “… sons for the popularity of homeopathic practitio-
one way or another to either users, their health- ners is that they take a very detailed and complex
care providers or acupuncturists.” A strong plea history and match the unique symptoms as
was made for good-quality research. described by the individual to a remedy designed
There are potential dangers in the use of acu- for that person alone. However, this means that it
puncture in asthma if it desensitizes individuals is very difficult to study homeopathy in placebo-
to symptoms that require attention. On the other controlled studies using standard extracts.
hand, acupuncture may, under specific situations, Some studies of homeopathy have shown ben-
help those who have pain, discomfort, or extreme efit, others have not. The latter have been criti-
stress. The question about the wider use of acu- cized because the use of a standard extract in
puncture in asthma care remains open at this time many individuals violates the principle of speci-
(Fig. 12.1). ficity of the individual. One study that showed
benefit was a randomized double-blind placebo-
controlled trial of homeopathy remedy and pla-
12.3.4 Homeopathy cebo of 144 hay fever sufferers over 5 weeks
[58]. Skin tests and IgE were also done to con-
Homeopathy is popular worldwide, with an esti- firm the diagnosis. There was an initial worsen-
mated 500 million people using it. In the USA a ing of symptoms, which homeopathic theory
1990 study estimated that 2.5 million Americans followed by consistent improvement in weeks 3
use it [10]. The 2012 National Health Interview to 5. In a placebo-controlled study of 51 adults
Survey estimated that 2.2% of US adults and with hay fever, benefit was shown [59]. The same
1.8% of children used homeopathy within the last investigators reviewed evidence from a number
year [57]. It is very extensively used in Europe, of studies, all of which had shown benefit [60].
and its remedies are available in all French phar- More recent studies have however yielded dif-
macies. Given that many homeopathic remedies ferent results. In a study in Oslo with 73 children,
are available over the counter, their use does not adolescents, and adults, no benefit was shown in
necessarily imply consultation with a homeo- a comparison of the homeopathic treatment for
pathic practitioner. England has hospitals devoted birch pollen allergy versus placebo [61]. Lewith
to homeopathy. In the USA there are estimated to et al. [62] did a double-blind randomized control
be over 3000 practitioners, with many of them trial of 242 people with asthma and positive
also having the qualification MD. results to skin prick test for house dust mite. They
were followed for 4 weeks and then randomized Massage affects the soft tissue and circulation,
to receive oral homeopathic immunotherapy or can reduce muscle pain, and also has a generally
placebo. They were then assessed over 16 weeks relaxing effect, which can be very beneficial.
with clinic visits and diary assessments, and out- Many CAM and conventional practitioners use it
come measures were obtained relating to FEV1, [25]. For example, physiotherapists and sports
quality of life, and mood. There was no differ- medicine specialists use massage, but so do chi-
ence in outcomes between placebo and homeo- ropractors, osteopaths, and naturopaths. There
pathic immunotherapy. Some of them improved, are also groups who do therapeutic massage only
but this was independent of belief in complemen- with training specific to the modality.
tary medicine or type of treatment. A British Massage has been shown to help anxiety and
report “concluded that not only was there little depression. There are few studies of massage in
evidence to support the efficacy of homeopathy, asthma or allergies. Field et al. [66] studied 32
but the data that did exist were of poor quality children with asthma who received either mas-
and came from trials that were often deeply sage therapy or relaxation therapy. Parents were
flawed” [63]. taught to provide one or other therapy just before
The conflicting results obtained from these bedtime over the course of a month. After mas-
studies are not easily explained. It has been sage, younger children showed a decrease in
pointed out, by those practicing homeopathy, that anxiety. Their attitude toward asthma improved.
this may well be due to the lack of individual (or Older children had lower anxiety after massage
“specific”) attention. In addition, most of the but with less benefit. However, the older children
clinical trials which showed benefit were found did show some improvement in FEF25–75. This
to be methodologically flawed [64, 65]. Hunter study then showed some benefit of daily mas-
[63] concluded that, in published studies of sage. It is not possible to know whether this is
homeopathy, “Common problems included nonspecific reduction in anxiety or related to
under-powered studies, failure to analyse by increased contact with specific time with parents
intention to treat, and failure to use allocation or to some other factor.
concealment.” In addition, “some of the pub- Therapeutic massage would not seem to have
lished systematic reviews are criticized for pool- any particular dangers, but evidence of its spe-
ing clinically heterogeneous data.” In other words cific benefit (rather than nonspecific reduction in
high-quality trials are essential before we get anxiety) is difficult to find. For example, the
good evidence. Bowen technique is popular. This form of mas-
Many homeopathic practitioners support the sage started in Australia after the Second World
use of conventional medicine along with homeo- War, but many countries now have trained practi-
pathic remedies, and this is a safe approach that tioners [67]. The specifics of the method are only
educators may wish to encourage. There is available to those who have undergone training
unlikely to be any toxicity with the dilutions used by an accredited center [68]. Despite the belief of
by homeopathy (Fig. 12.2). its followers that it is useful in asthma, no evi-
dence of its benefit could be found [16].
12.3.5 Massage Therapy

12.3.6 Naturopathy
A very popular form of CAM in the USA [3],
massage therapy is based on the common obser- Naturopathic healers undergo some undergradu-
vation that touch and movement are important to ate education at a college or university and then
every person. Whereas chiropractic deals with specific training leading to the degree ND (doctor
bones and joints, massage therapy deals with soft of naturopathy). Naturopathy has no single
tissue. In use since ancient times, it has enjoyed a underlying theory, apart from a strong belief in
recent resurgence in popularity. the natural healing power of the body. It is diffi-
cult to evaluate whether or not naturopathy 12.4.1 Herbs

approaches in general would help asthma, given
that a multitude of different modalities, such as Herbs are plants that are used as medicines, rather
herbs, massage, and nutrition, are used. Some than for food. They are also known as phytochemi-
specific subsections of naturopathy may help cals. Plants are the historic source for many of
asthma, and some of these (such as herbs and today’s successful pharmaceutical preparations.
nutrition) will be described later in this chapter. For example, the heart medicine digitalis was
One example is in an article from India, describ- obtained from foxglove. Digitalis is potentially
ing the use of naturopathy and yoga in bronchial toxic, and present-day preparations of digitalis are
asthma [69]. The outcome was a feeling of well- purified, with standard and specific doses. Aspirin,
being but not objective improvement in the an ancient remedy with new uses such as in the
asthma. prevention of heart disease, was also first identified
While the major underlying belief is in the in a plant as are some modern cancer medications,
natural healing power of the body, other beliefs such as Taxol. The Chinese herb ma huang con-
also exist. For example, naturopaths believe that tains ephedra, also purified as ephedrine. This acts
a cause of disease will always exist and that it can as a weak bronchodilator but is potentially toxic.
be found in the environment and lifestyle of the Today, there is a considerable difference
individual. This cause is thus related to the indi- between pharmaceutical medicines and herbal
vidual and not to external forces such as germs. medicines. Plants are now the source for a minor-
Cure cannot be obtained until this individuality of pharmaceutical medicines rather than the
specific cause is identified. Avoidance of harm is majority. For those pharmaceuticals that do have
another principle that is easy to understand and a plant origin, the active ingredient may have
support. A final belief is that only a holistic been identified. This then will be manufactured
approach will work. In other words, one cannot and processed with strict legal controls on the
treat a symptom in one system in isolation, but purity and strength of the end product.
one has rather to treat the whole person. All medications are governed by strong,
There are many benefits to naturopathy, legally enforceable regulations (enforced, in the
including the encouragement of a healthy life- USA, by the Federal Drug Administration). Proof
style. However, variation between practitioners is of the efficacy of pharmaceutical medicines must
so large that general advice cannot be given. A be given before they are licensed for sale.
number of practitioners will be antagonistic to Developing the required proof can be an expen-
medicine and may encourage people seeking care sive process, with costs of over $500 million not
to avoid immunization and standard medical uncommon. Herbs, in contrast, can be produced
care. By itself naturopathy is safe, and, when and sold without any demonstration of efficacy
combined with conventional medical treatment, and with minimal requirements about safety.
it may well be helpful. And many naturopathic They are not regulated by the FDA.
practitioners are willing to cooperate with con-
ventional medical practitioners [70].
Points to Ponder
The word “natural” does not imply—and
should not be taken to mean—that a prod-
12.4 Self-Help CAM uct is safe.
The final series of CAM are a variety of treat-
ments that can be used on a self-help basis. They Herbs, when used as medicine, may be:
include herbs, exercise, electromagnetic treat-
ment, aromatherapy, reflexology, and nutritional • The whole plant
approaches, particularly with supplementary • Plant parts such as the flower, bark, stem, or
vitamins and minerals. root
• Prepared dry or fresh, ground and put into [61], with four individuals so severely affected
pills or capsules, or made into a liquid that they required hospitalization [71].
The words “standardized extract” on a label

imply there is a specific amount of a substance Points to Ponder
present. However, such labels are unusual. Patients should be made aware that herbs
In advertising and literature about herbs, the can interact adversely with medications
word “natural” is used frequently. This word is (both prescribed and over the counter) or
seductive but misleading, especially when used can potentiate their actions.
in advertising. The consumer may assume that
natural means safe. This is not necessarily so, as
there may be toxicity contained within the herb.
Healthcare professionals may think that harmless The Physicians’ Desk Reference (PDR) pro-
means ineffective. This is also not true. Some of vides information on herbs used for asthma and
the herbs have specific and quite potent effects. comments on safety and efficacy [72]. Of those
As an extension of the concept of effect, some listed, the PDR is clear that, for most of them, the
herbs may interfere and increase the side effects evidence for benefit is poor. The list includes
of a pharmaceutical medicine that is taken at the astragalus, black walnut, chickweed, coltsfoot,
same time. The pharmaceutical medicine may comfrey, echinacea, elecampane, eucalyptus,
become more portent, or weak, when taken in fenugreek, garlic, ginkgo biloba, ginseng, hore-
combination with herbs. hound, kelp, kola nut, lobelia (also called asthma
The issue of safety of herbs is dealt with quite weed), pennyroyal, milkweed, mullein, myrrh,
differently in Europe than North America. In snakeroot, nettle, and thyme.
Germany herbs are evaluated for safety and effi- Some herbs are likely hazardous for asthma.
cacy, and there are good descriptions of what is These include kava, snakeweed, snakeroot, wall-
available and the standards for their production. wort, yagona, and yohimbe. Yohimbe can cause
There is no such standard in the USA, where respiratory problems.
herbs are currently regulated under the Dietary People who work with herbs may become
Supplement Health and Education Act. If the allergic to them [73, 74]. It follows also that it is
companies or people selling them avoid making a possible for those using herbs to develop aller-
claim for a specific disease, there is no need to gies to them. Given that herbs do not have to
prove efficacy or safety. This latter means that, demonstrate efficacy before they can be sold and
because of the way the law is phrased, it is diffi- given the fact that their preparation may vary
cult to find herbs specifically recommended for from one batch to the next, it is difficult to make
asthma by the companies or people selling them. specific recommendations. There are an enor-
However, there are some herbs which may be mous number of herbs in use and each has to be
helpful to individuals with asthma and allergies evaluated, and at present the literature is inade-
[25]. These include such substances as horserad- quate to make any determination of usefulness
ish, perhaps helpful if there are problems with on any herbs in asthma on its own merits [75].
sinuses. Cava may be helpful in decreasing stress Those with asthma who wish to use herbs
and anxiety. Myrtle may help with cough [25]. should consult their friends and find out what
Some literature suggests that echinacea may be they have found to be useful. They should buy
helpful with colds and flu, but the evidence is products from a reputable manufacturer. In addi-
conflicting. Unfortunately, echinacea may cause tion, they should consult with their pharmacist or
an anaphylactic reaction. An allergist evaluated other healthcare professional to check that there
five individuals with adverse events to echinacea, is no interaction between the herb they are about
two of the events being anaphylaxis [66]. There to use and their conventional pharmaceutical
were also adverse drug reports from Australia preparation.
Some dietary changes will make a difference.

For example, it has been shown that a low-salt
diet in men and women will give some protection
against exercise-induced asthma [76]. It is impor-
tant not to over respond to such reports, as it is
unlikely that changing dietary intake will com-
pletely abolish exercise-induced asthma and such
a dietary change may bring about other, unpre-
dictable, changes.
When severe food allergies exist and are
proven, there is a need to eliminate specific
Fig. 12.2 Ephedra in Chelsea Physic Garden. (Physic foods because of the allergies. Such food elimi-
means “healing”). This garden was founded in 1673 by nation diets should only be started on the advice
apothecaries, professionals who diagnosed, prescribed
of someone skilled in testing for allergies, and a
and dispensed medicines. At that time medicines were
based on plants. With the present revival of interest in registered dietitian should be consulted to
herbal medicines, the Garden’s educational programs are ensure that the new diet is balanced. Modification
again popular. (© I Mitchell) of the diet because of proven food allergies is
very important for those affected. Again, this is
There has been a revival of interest in herbal a different topic from using nutrition and nutri-
medicines as shown in the Chelsea Physic Garden tional supplements as a treatment to “cure the
(Physic means ‘healing’). This garden was asthma.”
founded in 1673 by apothecaries, professionals Milk allergies, while relatively common in
who diagnosed, prescribed and dispensed medi- infants and small children, are much less com-
cines. At that time all medicines were based on mon thereafter. An additional common belief,
plants. It offers educational programs that are which is separate from a belief in allergy, is
again popular See Fig. 12.2. that taking milk produces mucus. This belief is
pervasive and is not related to the educational
level of those who hold it. There is no evidence
12.4.2 Nutrition and Nutritional for this belief [77]. There is a significant risk to
Supplements avoiding milk, as it may lead to a diet deficient
in calcium and vitamin D, both of which are
The choice of foods that is consumed is impor- important for the development of healthy
tant to everyone. As with everyone else, individu- bones.
als with asthma and allergies should have a Because of confusion over the issue of dietary
well-balanced diet high in fruit and vegetables. supplements, the National Institutes of Health
This section however deals not with nutrition per has a separate office of dietary supplements
se but with nutrition as one treatment for asthma. (website http://ods.od.nih.gov). The Dietary
In this context, “nutrition” usually refers to diets Supplement Health and Education Act defines a
with supplemental material added, diets with sig- dietary supplement as a:
nificant food groups eliminated, or diets with
additional vitamins at a dose much higher than Product (other than tobacco) intended to supple-
usually recommended. There is a danger with ment the diet that bears or contains one or
dietary manipulation that there will be significant more of the following dietary ingredients: a
deficiencies in important nutrients, or conversely vitamin, mineral, amino acid, herb, or other
of toxicity because of overuse of substances botanical
which should normally be present in trace A dietary substance for use to supplement the diet
amounts only. by increasing the total dietary intake
A concentrate, metabolite, constituent, extract, or Overall, there is little justification for nutritional
combination of any ingredient described above supplements. Low-dose supplementary vitamins
Intended for ingestion in the form of a capsule, are safe, although whether it is better to obtain
powder, soft gel, or gel cap and not repre- these vitamins and mineral supplements within a
sented as a conventional food or as a sole item well-balanced diet containing fruit and vegetables
of a meal or of the diet or in a tablet or capsule is a moot point. An addi-
tional general concern is that the labels may not be
Some nutritional supplements produce mea- accurate. This is a worldwide concern.
surable changes. For example, a multivitamin The International Olympic Committee (IOC)
mineral supplement with selenium, zinc, vitamin released a report showing that 94 of 634 samples
A, vitamin B6, vitamin C, and vitamin E taken of nutritional supplements tested contained sub-
for 6 months was associated with a significant stances not listed on the label that would have led
increase in lymphocytes positive for CD3/IL4 to a positive doping test [81]. The same findings
[78]. It does not follow that this is necessarily are likely in supplements used by persons with
helpful, and a study in Britain would suggest just asthma. The IOC made a plea to governments
the opposite—that this diet was not helpful. This that controls be applied to the production of
study (the Heart Protection Study) [79] randomly nutritional supplements.
assigned 20,536 UK adults with coronary disease
or diabetes to receive antioxidant vitamin supple-
mentation (similar to the combination used in the 12.4.3 Exercise as Treatment
previously quoted study) or matching placebo.
No significant differences were found after Exercise is part of a healthy lifestyle, and all indi-
5 years of treatment. Although the study was viduals should choose a form of exercise that
directed specifically to coronary disease, there they enjoy and can use regularly. In individuals
were enough subjects to look at the effect on with asthma, exercise is a specific problem as it
other diseases, including respiratory diseases, may be a trigger to asthma. Educators should
and here too no benefit was found. It was, how- help them understand the issues involved with
ever, reassuring that the preparations used were exercise-induced bronchospasm and how they
safe. can continue to exercise despite the asthma.
Vitamin C is also an antioxidant vitamin and This section, however, deals with exercise as
has been proposed as a treatment for asthma. something of specific benefit to asthma, rather
The Cochrane systematic review looks at phar- than as something that is generally good to do
maceutical substances, herbs, and nutritional [25]. Exercise may be a form of aerobic respiration
supplements alike to determine what the evi- when there is an adequate supply of oxygen to
dence is for their use. Techniques used by the combine with glucose to provide energy. Anaerobic
Cochrane group are very carefully determined respiration occurs when there is insufficient sup-
and are public. In a review of vitamin C supple- ply of oxygen, perhaps because of the intensity or
mentation, 65 studies were initially reviewed, duration of the exercise or because of disease.
ten of these seemed to be of high caliber, but Exercise may also be subdivided into resis-
only six met the inclusion criteria as studies that tance and endurance exercise. Resistance exer-
would give a reliable answer to the benefits of cise using weights, for example, will increase
vitamin C supplementation in asthma [80]. Their muscle bulk and will make muscles more power-
conclusion, after review, was that there was ful. In endurance exercise there is less resistance,
insufficient evidence to conclude that vitamin C but muscle activity is prolonged. In endurance
had a specific role in asthma. They did feel that a strategy, many more muscle fibers are involved.
much stronger and larger scale study was There is no evidence that either form of exercise
required to address the benefits of vitamin C. is better as far as asthma is concerned.
In addition to its cardiovascular benefits, 12.4.6 Reflexology

which are well-known, exercise has a direct effect
on the lungs. More lung units will be open and In reflexology, specific points on the foot are
there is less likely to be atelectasis. An improve- believed to correspond to the various body
ment in general fitness is important for individu- organs. Pressing on the “correct” spot on the foot
als with asthma as it is for other individuals. may relieve the symptoms of a variety of dis-
Regular exercise may also help mood and may eases, including asthma [18]. In one double-blind
help to cope with stress and anxiety. placebo-controlled study [49], individuals with
Overall, regular exercise, while it may not cure asthma were allocated to reflexology or sham
the asthma, has significant benefits to the whole per- reflexology [83]. No benefit was shown with
son. It has specific benefits to the lungs and it should either approach.
be encouraged. It can also help with weight loss.
For more details on exercise and asthma, see
Chap. 5. 5.13. 12.5 Approach of the Educator
Educators, influenced by comments made by col-

12.4.4 Electromagnetic Treatment leagues and friends, will have views on CAM as
will those who come for asthma education who
Electromagnets have been used for many genera- are influenced by family, neighbors, and many
tions, and it is thought that the magnetic fields professionals. A study in Canada [84] found that
they generate have specific health effects [25]. most users get their information from:
There is controversy over this in general, but no
specific claims have been brought forward for • Family or friends (65%)
asthma. Electromagnetic therapy is safe. • Books (40%)
• Health food stores (37%)
• Pharmacies (35%)
12.4.5 Aromatherapy • The Internet (29%)
• CAM health providers (28%)
Aromatherapy is the use of the power of scent— • Hospital clinic (27%)
of the fragrance produced by plant oils—as treat- • Main stream health providers (26%)
ment. It is popularly believed that some volatile
substances will help clear the nose, including lav- Whether adults or children, persons with a
ender, eucalyptus, and peppermint. Given the chronic disease such as asthma are more likely
hyperresponsive nature of the airway in asthma, to use CAM than those who do not have a
care must be taken that aromatherapy will not chronic illness. Adults with asthma, particularly
worsen the asthma. women with a college education, tend to be
Numerous and widespread claims about aro- users of CAM [85, 86]. CAM use is also
matherapy’s benefits have not been supported by inversely linked to income. The use of CAM in
any evidence. In a well-known lawsuit in those with asthma ranges from 51% to 89%
California, a company that made innumerable [87]. The more severe the asthma, the greater
claims about its aromatherapy was sued by the the use of CAM [88].
National Council Against Health Fraud. The The knowledge that CAM is in widespread
claims included statements that aromatherapy use is important for the educator and mandates
promoted health, relaxed the user, purified the that the educator find out whether they are using
air, relieved fatigue, nourished the skin, pro- alternative forms of healthcare [89]. The educator
moted circulation, and so on. The courts found needs to use neutral, nonjudgmental questions to
that the aromatherapy company had violated receive a truthful answer. A question might be
California law by advertising its products with “Some people find that these treatments are very
false claims [82]. helpful. What do you think?”
12.5 Approach of the Educator 439
The popularity and widespread use of many of Potential areas of harm include restrictive
the alternate preparations does not mean that they fad diets or herbal or traditional medicines
are either safe or effective. However, it is impor- that contain potentially toxic substances.
tant to maintain lines of communication with the Professionals need to be aware of legal liabili-
individual with asthma, and suggestions have ties if they do not take due care in the advice
been made to healthcare providers that they they offer on CAM or the referrals they make
should provide “constructive feedback with to CAM practitioners [93].
regards to the safety and efficacy of these modali- Overall, the educator must use a supportive
ties in an unbiased fashion” [90]. approach, as it is unlikely that deep-seated
In some circumstances, some CAM may well beliefs about CAM will be changed during a
be effective when combined with conventional brief discussion. Most individuals seem willing
measures, but there are also dangers. Most CAM to continue conventional medication together
measures and treatments are safe, provided that with CAM, particularly if there is a good rela-
they are added to regularly prescribed asthma tionship between all involved. An example is
treatment [2, 91, 92]. given of a family who wished to use homeopathy
for their child’s asthma and a nurse who worked
constructively with them and who listened care-
Case Study fully as they described their interaction with the
allergist and the homeopath. The nurse was able
Sally Marks has had a difficult time with to maintain the family’s confidence, as the child
her asthma. Despite high levels of inhaled was treated both by an allergist and a homeopath
corticosteroids, she had to take prednisone [94].
periodically in the last 5 months to get her Most people would welcome an assessment of
asthma under control. the ingredients of herbal medicine, and this is
When asked about environmental con- something an educator can arrange by reviewing
trols, she asserted that she had not pets or published material in association with a local
plants, did not smoke, used dust mite proof pharmacist.
covers on her mattress and pillow, had got The educator needs to caution them that thera-
rid of her carpets, and had taken all neces- pies that recommend total abandonment of medi-
sary environmental precautions that were cation can be dangerous. Users also need
recommended for control of her asthma. reminding that symptomatic improvement does
Specific questioning about what has not necessarily equate with an increase in pulmo-
changed in the last 5 months elicited the nary function or a reduction in airway inflamma-
response that she was “very much into mind- tion. The prescribing physician should be aware
body healing” even while taking all the pre- of alternate therapies being used [89].
scribed medications. To induce the right Local CAM practitioners may provide educa-
mood, she stated that she burnt “lots and lots tional materials. These should be treated in the
of candles, because of their soft light and same way as any other material. The educator
perfume.” They helped her meditate. should ensure that the reading level is appropriate
Sally was advised to stop burning the and that ideas antagonistic to the educators’
scented candles or any kind of candle for teaching are not promoted or highlighted. The
that matter. Unless made from beeswax, educator should have reference material on CAM
most candles are made from petroleum and may want to point out that conventional care:
products, and smoke from candles can be a
trigger for asthma, as can their nice scents. • Considers the whole person, encouraging
Once she stopped burning candles, her them to lead a full life
asthma was easily brought under control • Encourages a balanced diet and regular exercise
with a subsequent reduction in the level of • Focuses on prevention with an emphasis on
inhaled corticosteroids. the environment
Finally, there is a real possibility that major costeroids and a leukotriene antagonist, comes
advances in asthma care may be concealed in to visit you. Her best friend has explained the
CAM practices. The educator can best help not Bowen technique to her. She has now stopped
by advocating the unproven but by encouraging her medications. Her FEV1 has fallen, but she
high-quality research into the most promising feels fine and is active. Describe how you
modalities. would help her. Would it be different if she
Useful sources of information include: wanted to do the same with her 6-year-old
son?
• The National Institutes of Health website at
www.nccam.nih.gov/health. This is the site
for the National Center for Complementary References
and Alternative Medicine that has been funded
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Frequently Asked Questions
13
Contents
13.2 Asthma: Symptoms and Control 446
13.3 Triggers 449
13.4 Fatal Asthma 453
13.5 Exercise and Asthma 453
13.6 Medications 454
13.7 Testing and Devices 458
13.8 Spacers 459
13.9 The Peak Flow Meter 460
13.10 Allergies 461
13.11 School and Camp 463
13.12 Pregnancy 464
13.13 Travel 465
13.14 Coping 466
13.15 Immunizations 470
13.16 Other Questions 471
446 13 Frequently Asked Questions
(such as variable, triggers, inflammation, chronic,

Key Points and so on) in simple, nonmedical language.
• Individuals with asthma and their fami-
lies have numerous questions about this
condition. This chapter lists the most 13.2 Asthma: Symptoms
commonly asked questions about and Control
asthma, control, death, exercise, medi-
cation, devices, COVID-19, and Q. What is asthma?
allergies.
• A section is devoted to travel, coping, Asthma is a disease of the lung, more specifi-
and immunizations in asthma. cally, of the airways of the lung. It is a chronic
disease, meaning that it does not go away quickly,
if at all. It is variable (i.e., it can change from day
to day). Inflammation (swelling and reddening—
Chapter Objectives like a mosquito bite) of the airways causes most
After reading this chapter, you should be of the problems. The inflammation makes the air-
able to: ways very sensitive so that they narrow easily in
response to a wide range of triggers.
1. Describe the common concerns that
In addition to the inflammation, the muscles
individuals with asthma have about around the airways contract (get shorter and
their condition. hence “squeeze” the airways), and the cells lining
2. Answer individual and family questions the airways produce extra mucus. These changes
on asthma and its effect on daily living. make it difficult to breathe. Asthma is reversible,
meaning that with medication and environmental
control, the effect on the airways can be reversed.
Q. What are the main symptoms of asthma?
13.1 Introduction Cough, wheeze, shortness of breath, and chest

tightness. Sometimes only one symptom is pres-
Asthma raises fears and concerns—about the ent while at other times two, three, or all four can
condition, its implications, the medications used, be present.
and their side effects. Over the years, those with
asthma (and, in the case of children, their par- Q. What is a trigger?
ents) have tended to ask their healthcare p roviders
a wide range of questions about asthma and its This is any allergen or irritant that brings on
social and medical effects. the symptoms of asthma.
This chapter presents some of the questions
asked most frequently by parents and individuals, Q. What is wheezing?
together with suggested responses. While ques- Wheezing is a noise caused by air moving
tions have been grouped by topic for ease of use, out through the narrowed airways. It is heard
there is inevitably some overlap between topics, when you breathe out, not when breathing in.
and this should be borne in mind when reviewing Airways are blocked in asthma by:
this chapter. • Inflammation of the lining of the airways
The answers provided here are terse and brief. • Increased mucus production
In almost all cases, they will need to be explained • Tightening of the muscles around the air-
in more detail to the person concerned, and it ways leading to the airways being
may also be necessary to explain specific terms narrowed
13.2 Asthma: Symptoms and Control 447
Q. Is asthma psychosomatic? Q. What are the symptoms that warn me that my

asthma is going out of control?
No, asthma is not “all in the mind.” It is not Briefly, the symptoms that indicate that
imagined. It is a disease of the airways of the your asthma is going out of control include:
lungs. It can be affected by how you feel and by • Difficulty sleeping through the night
stress in your life. because of symptoms of asthma
• Difficulty exercising (doing things you
Q. Is asthma contagious? Can I get asthma if my normally do)
friend has it? • Shortness of breath (a sensation of not
getting enough air)
No. Asthma is not contagious. You can safely • Wheezing
be with friends and relatives who have asthma. If • Tightness in the chest
you are in school, some of your classmates (and • Drop in peak flow readings
friends) will undoubtedly have asthma. • Medication not working as well as usual
• Medication not working as long as usual
Q. Can I lead a normal life even if I have asthma?
Yes. It is important to first get your asthma Q. I have mild asthma. Does that mean that I
under control. Once your asthma is under con- will always have mild asthma?
trol, you can lead a normal life. There may be
things you may have to avoid, but this restriction Perhaps. When you were diagnosed with mild
or compromise is worthwhile since it will reduce asthma, the healthcare provider used the word
the chances of an asthma attack. mild to describe your symptoms at the time he or
she made the diagnosis. That does not mean that
Q. What does “under control” mean? your symptoms will stay the same. They can
change. There may be times when your symp-
It means that you do not have symptoms such toms will increase, and there may even be times
as chest tightness, wheezing, coughing, or dis- when the symptoms are severe. Asthma is a vari-
turbed sleep. It means that your medication is at able disease, and the symptoms will change from
the right dosage so that you have few or no side time to time, depending on the level of exposure
effects. It means that you do not have to take your to your triggers.
reliever medication more than twice a week,
except before exercising. Q. Is there a cure for asthma?
Q. Can asthma be controlled? Not at present. We hope that sometime in the

future, asthma will be “cured” but to date there is
Yes, by avoiding your triggers and taking no cure. However, while the tendency to have
proper medication, you can control your asthma. asthma is always present, it may not always be
It is not always easy to identify a trigger, and it present as it may come and go throughout life.
may require some personal detective work to
identify all your triggers. Q. My child has asthma and is quite short of
breath. He wasn’t able to go to school today.
Q. What does “good control” of asthma mean? Should I take him to a professional for
Good control means that you: assessment?
• Have few or no symptoms.
• Take the minimum amount of medication Yes. If his reliever medication does not help or
required to control your asthma. if he is having any difficulty breathing, take him
• Live a normal life. in immediately. Go to the ED.
Q. We had to take my daughter to emergency few hours to a few days. Symptoms are an indica-
because of her asthma. Wheezing was not tion that the airways have narrowed and that there
heard but she was still admitted. Why? is inflammation. The symptoms will fade with
Wheezing is a symptom that the airways appropriate treatment, but the underlying inflam-
are getting narrow so that the air is having dif- mation may take a long time to heal depending
ficulty moving in and out of the lungs. The on the severity of the initial attack and whether
wheezing can stop for two reasons: there is further exposure to triggers.
• Because the airways are no longer narrow
and the air can move freely Q. Why does our child sometimes vomit during
• Because the airways have become so nar- an asthma attack?
row that very little air is moving in or out
Asthma attacks and vomiting often go together
It was probably for this second reason that in children. The coughing may trigger the vomit-
your daughter was admitted. ing, but vomiting and abdominal pain may also
occur when the child is not coughing. Children
Q. I have had a cough for a long time. My health- report they feel better after vomiting up mucus
care provider says I have asthma. I thought and then they breathe better for a time.
wheezing was a sign of asthma.
Q. I had an asthma attack and seemed to get bet-
Different people have different symptoms. ter, but about 6 hours later, I had another
Sometimes cough, especially when it disturbs attack. I don’t understand what happened.
sleep at night, is the only symptom that a person (or)
has asthma. Your healthcare provider will have Q. The healthcare provider said my asthma is
taken a careful history before making the biphasic. What does that mean?
diagnosis.
Asthma attacks often occur in two steps or
Q. What is an asthma attack? phases. The “early phase” comes first or happens
first. Then, anywhere from 6 to 12 hours later, it
An asthma attack, episode, or exacerbation is is followed by what is called the “late phase.” The
the name given to the time when asthma symp- late phase is often worse than the early phase. So,
toms flare up. Coughing, wheezing, and short- when your doctor uses the term “biphasic,” these
ness of breath indicate an asthma attack or two phases are what is being referred to.
exacerbation.
Q. Most of my asthma attacks seem to occur at
Q. What happens when I have an asthma attack? night. Is this common?
An asthma attack starts because the lining of Yes. Nighttime symptoms are a clear indica-
the airways gets irritated and inflamed. The lin- tion that your asthma is not under control.
ing gets red and swollen. The cells in the lining If wheezing, coughing, or breathlessness
produce mucus that makes the airway even nar- wakes you during the night more than twice a
rower. Then the muscles around the airways go week, then your asthma should be reassessed and
into spasm—they tighten. That makes the air- the medication possibly adjusted.
ways very narrow.
Q. Will my child outgrow the asthma?
Q. How long does an asthma attack last? (or)
Q. I had asthma when I was young but I outgrew
Each asthma episode is the result of exposure it. Isn’t it possible for a person to outgrow
to different triggers. Exposure may occur over a their asthma?
13.3 Triggers 449
This is a common misconception. The ten- the underlying inflammation still has to be
dency to have asthma is always present. In those reduced and treated with medication. The second
with mild/moderate asthma, it may come and go possibility is that the airways have become so
throughout life. In more severe forms of asthma, narrow that very little air is moving in and out of
it will persist. your lungs. That is why wheezing cannot be
You may have been one of those children with heard. This is a very serious situation.
mild/moderate asthma who appear to outgrow
their asthma. There may be long periods when Q. How long do the lungs take to heal after an
asthma seems to go away. These are called remis- asthma attack?
sions, and medication will not be needed. You
may never have another attack. Then again, after In an asthma attack, the lining of the lungs is
a period of remission, your symptoms may restart damaged. It takes up to 3 months for this lining to
as will the need for medication. You have “twitchy heal, provided it is not exposed to other irritants
airways” and an asthma attack can occur at any and allergens—that is, provided you do not have
time. another attack in the meantime.
As you grew, the size of your airways
increased, and if you had severe asthma, you did Q. I have asthma and have just come out of hos-
not notice the symptoms of asthma as much as pital. Things that never bothered me before
you did when your airways were smaller. As a now trigger the asthma and make me cough
result, you are better able to handle the symptoms and wheeze.
of asthma.
In other words, the reduction in airway size The asthma attack you suffered has damaged
that occurs today due to inflammation does not the lining of your lungs. Now the lungs are even
have as much effect now as it did in the past, more sensitive than they were before the attack.
when your airways were smaller. Also, as you As a result, the lining of the airways will react to
grew, you developed antibodies to many of the other irritants and allergens, and these, in turn,
common viruses. As a result, you got fewer can trigger more symptoms. You need to take
infections. extra care to not be exposed to triggers during
The significance of these various changes is this time.
really important. Deterioration in adolescence is
not unusual, partly due to this belief that the
asthma has been “outgrown.” 13.3 Triggers
Q. My asthma is well controlled, but I still keep Q. Do emotions cause asthma?

waking up at night and coughing.
No. Emotions do not cause asthma but they
Your asthma is not as well-controlled as you can be a trigger if you already have asthma. For
think. If you are waking up at night either because example, when you cry, or laugh hard, you may
of your cough or because you are short of breath, trigger an attack. This is because you are inhaling
it means that your asthma is not under control. air that is not warm, not clean, and unhumidified
You should see your healthcare provider and together with all the pollutants in the air. All
tell her or him about this problem. those combined will irritate your airway.
Q. When I stop wheezing, that means the asthma Q. Can a stressful situation cause my child to
attack is over. Is that correct? have an asthma attack?
No. When wheezing stops, it can mean one of Yes, if the child already has asthma. A
two things: you have reduced the symptoms, but stressful situation may evoke a strong emo-
tional response from any child. Unfortunately Q. We’ve had our cat for a long time. My hus-
for the child with asthma, this emotional band has just tested allergic to cats. If we get
response may trigger an asthma attack. The rid of it, will it help his asthma?
physical changes that go along with stress may
be the actual trigger. Sobs, for example, lead to Yes. Finding a new home for the cat will cer-
deep breathing. This allows cooler unhumidi- tainly help your husband with his asthma.
fied air to reach the lower airways and trigger However, it will take about 3 months of thorough
asthma. cleaning to remove the cat dander from the furni-
ture, carpets, drapes, walls, and around the house.
Q. Can food trigger asthma? You may not see any effect for about 2 months,
but in the long run, your husband will benefit
Food can be a trigger for some people. In from the removal of the cat.
some cases, even the smell of food can be a trig-
ger. For example, someone allergic to fish may Q. I am allergic to cats so we gave our cat away
walk by a fish store and start wheezing. for 2 weeks, but it didn’t make any difference
to my asthma.
Q. Is there a special diet that can control and
prevent my asthma from occurring again? It will take a lot longer than 2 weeks before
you begin to notice a difference. Even though
No. While you can help control your asthma your cat is now out of the house, it has left its
by avoiding those foods that may be a trigger for dander everywhere, and you are continuing to
you, there is no diet that actually controls and breathe in the dander.
prevents asthma. Different people have different In 2 weeks, you will have made only a small
asthma triggers. To help control your asthma, you dent in the task of dander removal. It will actu-
must avoid your triggers. ally take about 3 months of regular, intensive,
and thorough cleaning to get rid of all the
Q. What kind of infection triggers asthma? dander.
The infection that causes most trouble is the Q. If I keep my pet out of my bedroom, will my
ordinary family of viruses that cause a head cold. asthma go away?
With someone who does not have asthma, a head
cold lasts a few days. When you have asthma, It would certainly help if you did not have to
wheeze often starts on the second or third day of sleep in the same room as your pet. However, the
the cold, and there may be coughing at nights for dander from your pet may be circulated by the
weeks. air-conditioning and heating system of your
home. Keeping a pet out of your room may help,
Q. Every time my child gets a viral infection, I but it will not take away your asthma.
notice a sharp drop in my child’s PEF, fol-
lowed by a severe asthma attack. What should Q. We have never had a cat. Recently we moved
I do? into a house where a cat had lived, and my
asthma has been worse. Why?
Follow the action plan created for your child.
If you do not have such a plan, ask your health- Cats leave behind dander, which contains their
care provider to give you one. It will tell you saliva. Most people are allergic to a protein in cat
what to do when peak flows fall, what medica- saliva. Cats constantly groom themselves by lick-
tions to give, and when to give them. ing their fur, and this protein is transferred to
13.3 Triggers 451
their fur. When the fur is shed, as it is all the time, Q. I vacuum regularly, yet there is always dust in
it makes its way into carpeting, onto upholstery my house. What can I do?
and many other places.
It takes at least 3 months of regular, intensive Tracing the source of dust in a house can be a
cleaning to rid a house of cat/pet dander. challenge. In many older homes, plaster flakes
from walls or ceilings may be one source of dust.
Q. My asthma is triggered by exercise, dust, and If the ceiling is made from exposed timber planks
pollen. Why should we find a new home for or beams, dust may also drift down from between
our cat and have a “no smoking” rule in the the beams.
house? Many portable vacuum cleaners contain a fil-
ter that is supposed to trap the dust that they suck
Many families with a dog or a cigarette smoker up. However, some of this dust does escape back
will blame a chronic cough or runny nose on a into the air. In effect, some of the dust that lay
known allergen. However, the continual presence of inside your carpet or on your floor is now put
allergens or irritants causes a continual low-grade back into the air, and it can settle on furniture
inflammation in the airways. This can develop into immediately after you vacuum. This could be
an asthma attack if there is exposure to a trigger. another source of dust.
Symptoms can appear up to 3 days after the expo- If your windows are kept closed most of the
sure. Thus, reduction or avoidance of allergens or time, and if the dust is coming in through cracks
irritants will make the asthma more manageable. around windows or under doors, consider sealing
all such openings. If you have done this yet still
Q. What is a dust mite? I tested allergic to them. see dust, and if you have forced-air heating or air-
conditioning, the air ducts in the house may need
Dust mites are microscopic creatures that live cleaning. (A furnace or air-conditioning service
in our houses and thrive on the particles of skin company can do this.) If this still does not solve
that we shed every day. They are to be found in the problem, here are some other things you can
warm, moist areas such as beds, carpets, sofas, try:
curtains, and anywhere we live.
• Use multilayer bags in your vacuum cleaner.
Q. How can I get rid of dust mites? • Consider buying a cleaner with a HEPA filter.
• Install a built-in (or central) vacuum system
Dust mites cannot thrive in low humidity. One that is vented outdoors. This will make a
way to control dust mites is by keeping the difference.
humidity in your home below 50%. Washing bed • Install an electronic air filter on your furnace.
linens weekly in hot water at 130 °F (55 ̊ °C) or This can also help reduce the amount of dust.
even cold water which will drown them, will also
help.
Q. Cold air triggers my asthma. Why does that
Q. How can I reduce my exposure to dust mites? happen, and what can I do to prevent it?
Special coverings for pillows and mattresses When breathed in, cold dry air can trigger an
will help reduce your exposure to dust mites. To asthma attack by cooling and drying the airways.
achieve this, remove any carpeting in your bed- Attacks are more common in cold weather. They
room. Reduce the amount of dust by frequent can be prevented by breathing through the nose
dusting with a damp cloth. Wash linen preferably instead of the mouth or by covering the nose and
in hot water and remove all items that are “dust mouth with a scarf so that the inhaled air is
catchers” from your bedroom. pre-warmed.
Q. Since my asthma is affected by tobacco Use washable curtains instead of drapes.

smoke, my husband smokes outside the house. Hardwood, laminate, or linoleum flooring is pref-
Will this help me? erable to carpeting. Avoid stuffed furniture.
Remove books, toys, and other dust catchers
It will certainly reduce the amount of tobacco from the bedroom.
smoke you are exposed to, but you must remem-
ber that when he comes back into the house after Q. What items should we ban from the
smoking a cigarette, he will bring in the smoke bedroom?
on his hair, his skin, and his clothing so that you
will still be exposed to tobacco smoke. All items that can collect dust, such as uphol-
stered furniture, stuffed toys, trinkets, paintings,
Q. I have asthma and live in an old house. We posters, and book shelves.
have thought about moving to a brand-new
house. Will such a move help my asthma? Q. Should we remove the carpet in our
bedroom?
As long as your present house is not damp,
think twice before moving. The materials used to Unless your asthma is severe, there is no need
build a new house such as the particle board, to remove the carpet. Careful, thorough vacuum-
paint, carpets, and drywall all give off gases, ing every week, followed by steam cleaning
which may act as triggers for your asthma. “Off- twice a year, should suffice.
gassing,” as it is called, can continue for up to
2 years after a house is built. By moving to a new Q. My wife loves her house plants but she has
house, you may actually make your asthma asthma. If we cover the soil with wood chips,
worse. New houses also smell of paint, sealing can we keep the plants in the house?
compounds, glues, and other noxious substances
that affect people with asthma. Plant soil contains mold. If your wife’s asthma
Some builders make new homes with materi- is triggered by mold, then it is best to get rid of
als that are not known to cause much in the way the plants. Covering the soil with wood chips will
of trouble and with extra filters on the heating not prevent the mold from thriving in the soil.
and vacuum systems. These homes are expen- She should be aware that working with plants
sive, and there is no evidence at present that they exposes her to the mold in the soil. If she doesn’t
will make any difference to the asthma. want to give up her plants, then she should reduce
their number and have someone else water and
Q. We’ve thought of putting in a humidifier to care for them. Do not keep any plants in the
help our child’s asthma. Will it help? bedroom.
A humidifier is not advised for children or Q. What effect does tobacco smoke have on
adults with asthma. First, it can become a source asthma?
of mold that can be spread through the house.
Second, a humidity level of over 50% will Tobacco smoke irritates the lining of the air-
encourage the growth of dust mites. Most people ways. This increases the severity of asthma
with asthma are sensitive to dust mites. symptoms. Tobacco smoke is a known trigger
of asthma. It also reduces the effectiveness
Q. What can we do to make our bedroom as of your inhaled corticosteroid asthma
dust-free as possible? medication.
Use mattress and pillow covers that are made Q. My father has been a lifelong smoker. He
of plastic or a material impervious to dust mites. refuses to quit smoking even though my
13.5 Exercise and Asthma 453
mother has been diagnosed with asthma. Is Q. Is asthma life-threatening?

there any way we can help her?
Asthma can be life-threatening, but few peo-
Your father is unlikely to change, but you can ple have severe, life-threatening asthma which
discuss with him the harmful effects that his needs treatment in a hospital. Avoiding triggers
smoking is having on your mother. Perhaps that and taking preventive medication rather than
will motivate him to change. reliever medication on a regular basis can prevent
What you can do is try to minimize your most episodes of asthma.
mother’s exposure to tobacco smoke. Would he
be willing to smoke outside the house? Could Q. Why should I take my asthma seriously?
they come to some other kind of agreement or
compromise? Asthma is a disease. All diseases should be
taken seriously because of the potential harm
Q. My daughter has a rather severe pollen they can do to the body. Untreated asthma, for
allergy. We are thinking of moving to the example, can cause irreversible damage to the
coast to get away from the pollens here. Is lungs. Damaged lungs can seriously limit your
there anything we should consider before we lifestyle. If your asthma is deteriorating and it is
make the move? left untreated, you can die from it.
There is no guarantee that moving from one

area to another will help your daughter. It may
help initially, but she will likely become allergic 13.5 Exercise and Asthma
to the pollen in the new area due to cross-
reactivity. Further, pollen is windblown and can Q. I have an asthma attack every time I exercise.
travel for thousands of miles. Pollen has even Should I stay away from exercise?
been found in the Arctic. So, getting away from
pollen is difficult. No. First make sure that your asthma is under
Talk to your daughter’s allergist about allergy control. Then, if exercise is a trigger, premedicate
shots to the specific type of pollen to which she is with a short-acting bronchodilator or reliever
allergic. (your healthcare provider will know which medi-
cine is best for you). For some special occasions,
a long-acting bronchodilator may be needed
13.4 Fatal Asthma before exercise. Take your medication about
20–30 minutes before you start your warm-up.
Q. Can you die from asthma? Do a slow warm-up. Follow that with your cho-
sen exercise and then do a slow “cooldown” for at
Yes, but this is rare. If untreated, asthma can least 10 minutes.
be fatal. Death from asthma can almost always be
prevented, and it is even rarer for asthma deaths Q. What is a slow warm-up and slow cooldown?
to be unexpected or sudden. Here is a suggested routine:
If you do not treat your asthma, the damage to • First, do 5 minutes of stretching.
the airways may become permanent. Death from • Next, 5 minutes of walking.
asthma can result, and although this is rare, it is • Finally, do 5 minutes of more strenuous
usually because warning signs have been ignored. exercise.
In the USA, ten people die every day from
asthma-related complications. Most of these To do a slow cooldown, reverse the order of
deaths could have been prevented. the warm-up.
Q. Why is it necessary to do a slow cooldown? 13.6 Medications
If you have exercise-induced asthma, then Q. What is the difference between relievers and
your asthma is first triggered when you start exer- controllers?
cising. However, about 10 minutes after you fin-
ish exercising, the second phase of the attack may These names really say it all. Relievers give
begin. To prevent this second phase, you must do you almost immediate relief from the symptoms
a slow cooldown. of asthma. They reduce the shortness of breath,
the constriction, and the spasm of the airways.
Q. Sometimes when I exercise, I get short of However, they only provide temporary relief.
breath, but if I keep exercising, then it goes They do nothing to treat the problem. They do not
away. treat the underlying inflammation of the airways
that is the cause of asthma attacks.
There are two phases to exercise-induced Controllers are medications that are specifi-
asthma, or “EIA.” The first phase can be mild, cally designed to reduce and prevent inflamma-
and if you continue to exercise through it, this tion of the airways. They take longer to work, but
sometimes reduces the effect of EIA. This is they provide long-term relief. Many people with
known as the refractory period. But it only lasts asthma require both relievers and controllers in
as long as you are exercising. Once you stop, order to control their asthma.
your symptoms return because you are into the
second phase of the EIA. Q. Why should I take medication if I don’t have
any symptoms?
Q. I have asthma. Does that mean I cannot be
involved in professional sports? When you have asthma, it is only when your
symptoms flare up that you know you have
Of course you can! You may not be aware of inflammation. Unfortunately, symptoms are like
this, but a number of Olympic and professional the tip of the iceberg—when you finally get them,
athletes have asthma. They make sure that their you are already in serious trouble. Taking medi-
asthma is under control. Once your asthma is cation even when you do not have any symptoms
well-controlled, there is no reason why you can- prevents and reduces the inflammation in the
not take part in professional sports. lungs.
Q. Should our child, who has asthma, exercise? Q. Why can’t I just use my reliever medication?
Yes. Exercise will allow your child to fit in Reliever medication can be compared to
with his or her peers and strengthen the develop- makeup that you put on top of acne or a pimple.
ing heart and lungs. It eases the problem for a short time. Reliever
medication is just a short-term measure to relieve
Q. Why does exercise cause an asthma attack? the symptoms of asthma, the tightness in the
chest, wheezing, and shortness of breath that you
We don’t really know, but it may be the result feel. It does not fix the problem. It has no effect
of breathing cold, dry air into the lungs through on the airway inflammation that is causing the
the mouth. (Air breathed through the nose is symptoms. You also need something else—the
warmed and humidified before it reaches the air- controller medicine. If reliever medicines are
ways.) The attack usually starts 5–6 minutes after used regularly, the asthma may be helped at the
exercise begins and becomes more severe after time it is taken, but over time the asthma becomes
the exercise is over. worse.
Q. Why do you use steroids for asthma? Steroids usually prescribed for a specific reason, but
are to build muscles. another medication may work as well as or better.
Ask your healthcare provider to review your
There are many kinds of steroids, and many medication.
people confuse them. Some are bad for you; oth-
ers are good. Q. My healthcare provider said I should rinse
Anabolic steroids are bad and illegal. They are my mouth after taking my controller medica-
used mainly by athletes as performance enhancers. tion. Why?
Corticosteroids are “good steroids.” Our bod-
ies produce a corticosteroid, cortisol, that is Controller medications such as inhaled corti-
essential for our survival. The man-made coun- costeroids can cause thrush if the medication
terpart of cortisol is cortisone, and the molecule ends up at the back of your throat. To prevent this
has been modified many times to improve the from happening, rinse your mouth and spit after
safety of corticosteroid medications and also taking the medication.
make them more effective. When we take inhaled
corticosteroids for asthma, we are taking a deriv- Q. Why can’t I take Serevent to help me when I
ative of the same hormone that our body pro- have an asthma attack?
duces to help reduce inflammation of the
airways. Serevent is a long-acting bronchodilator. It
cannot be used as a reliever because it needs
Q. I had a slight cold and the healthcare pro- time to take effect. You still need your short-
vider suggested I double the amount of acting reliever medication to control symptoms
inhaled steroid. If the steroid takes a week to immediately. There is a long-acting bronchodi-
become effective, and the cold is gone in a lator called Foradil that starts to work right
week, what is the point of increasing the dos- away, and it has been used to relieve symptoms.
age of inhaled steroid? However, you should not make this change
without first discussing it with your healthcare
When inhaled corticosteroids are first taken, it provider.
can take a week or longer before they are fully
effective. They will have some effect on you Q. Our son’s best friend also has asthma but he
before a full week has gone by, depending on the is on a different treatment program. Why?
dose. The situation is different when inhaled cor-
ticosteroids are already being taken when a cold Each child is unique. There are many available
starts. Many healthcare providers, and those with treatments, and no two children are identical in
asthma, feel that if the dose of inhaled corticoste- the way their asthma develops, or the severity of
roids is increased very early in the course of a their asthma, or the way in which they respond to
cold, then the cold is much less likely to make the triggers. Since asthma is not a simple disease,
asthma worse. However, more recent evidence there is no one treatment. That is why your son’s
casts doubt on the benefit of doubling or even and his friend’s treatments have been customized
quadrupling the dose. Old ideas die hard! to meet their personal needs.
Q. Every time I take Tilade, I have a horrible Q. If I miss a dose of asthma medication, is it
taste in my mouth. Why can’t the healthcare alright to double the next dose?
provider give me a nice-tasting medicine?
No. Try and space the doses evenly, but if that
Tilade does have an unpleasant taste. You isn’t possible, just take the next dose at the nor-
could try rinsing your mouth after taking it. It is mal time.
Q. How long does it take for my medication to be Q. Every time I take my asthma reliever, my
effective? asthma gets worse. It makes me cough and
wheeze. What should I do?
It depends on the medication. Here is a table
for different medications: See your healthcare provider and ask about a
change in your medication. About 1 in 50 people
who take medication has an adverse reaction to it.
Medication Time needed to work
If your medication is making your asthma worse,
Oral corticosteroids 4–6 hours
talk to your healthcare provider immediately.
Inhaled corticosteroids 3–7 days
Theophylline 4–8 hours
Intal 2–7 days (peaks in Q. I had an allergic reaction to my Serevent
3 weeks) inhaler. I have no trouble with my Serevent
Anticholinergics 30–40 minutes Diskus. Does this mean that I am allergic or
Beta-agonists 1–15 minutes not allergic to Serevent?
Tilade 10 days
Long-acting bronchodilators 4–6 hours generally
Foradil 1–3 min and If you had a reaction to the inhaler, chances
30 minutes to are that you reacted either to the propellant or to
maximum the preservatives in the medication.
effectiveness
Q. I am allergic to colorings and preservatives.
Q. Can you become addicted to asthma How do I find out what is in my medication?
medication?
Talk to your pharmacist who is the best person
No. Asthma medication does not contain to advise you about the additives and excipients
chemicals that create addiction of any kind. (things added to the basic drug) in every medi-
cine you use. Be sure to ask about over-the-
Q. Will my medication become less effective the counter medications you may wish to purchase.
longer I take it? The pharmacist is trained to find information on
all medications and what they are made of,
The answer is “no,” if you are asking about including the colorings, flavorings, and
controllers, which are one kind of asthma medi- excipients.
cine. As long as you also take your controllers to
prevent the inflammation of the airways, the Q. Are there prescription medications that
medication will be effective. should not be mixed with asthma
For beta-2 relievers (the other kind of medi- medication?
cine), the situation is different. You must take (or)
your relievers as required to control asthma Q. Are there over-the-counter medications that
symptoms. However, if you rely solely on your should not be taken with asthma
reliever, then you are not treating the underlying medication?
inflammation, and the asthma can worsen. Your
reliever may stop being effective altogether or Yes. Always check with your pharmacist
may be partially effective for only a short time. because there are many products on the market,
When this happens, you will need medical atten- and individuals with asthma should stay away
tion urgently. from some over-the-counter medications. This
Hence, both relievers and controllers have to rule applies both to over-the-counter medications
be taken as prescribed. and prescription medications.
Q. Can we use cough syrup to treat nighttime and retention of sodium and water, obesity, facial
cough? mooning, impairment of wound healing, atrophy
of subcutaneous tissues, peptic ulceration, pre-
No. The cough syrup will not help. Persistent cipitation of diabetes, and development of cata-
nighttime coughing is almost always due to racts. It can also cause psychiatric disturbances.
asthma. It is a warning that the asthma is not con-
trolled and should be reassessed. Q. What sort of things can I expect when I come
off prednisone? I’ve been on it for 3 weeks.
Q. The pharmacist said that my son who has
asthma should not take Dramamine. Why? The side effect most reported by users is a
feeling of depression. You may also have mood
Dramamine has sedating properties. People swings.
who have asthma should not be given sleeping
pills or other medications that sedate them Q. Why should I take my prednisone in the
because these medications affect that part of the morning?
brain that also controls breathing.
The body produces natural corticosteroids.
Q. My healthcare provider said my asthma is so These are highest after noon, and taking the pred-
bad I need prednisone; but my neighbor said nisone in the morning helps raise the level of cor-
that prednisone will put hair on my chest and ticosteroids in the body at a time when they are
make me fat. What should I do? low.
Listen to your healthcare provider. Prednisone Q. I don’t like the idea of taking inhaled cortico-
is a steroid, in fact a corticosteroid, but it is differ- steroids. Why can’t I just take a prednisone
ent from the illegal steroids that athletes use to pill when the inflammation begins?
build muscle. Prednisone is extremely effective
in reducing and controlling the inflammation in There are two reasons. First, you cannot tell at
the lungs, which is why your healthcare provider what point in time the inflammation begins inside
wants you to take it. He will most likely prescribe the airways. Second, symptoms appear only after
it only for a short period of time. the inflammation has been present for some time,
and the airways are already narrow, swollen, and
Q. My healthcare provider suggested that I take constricted. Inhaled corticosteroids prevent the
prednisone only on alternate days. Why? occurrence of inflammation.
Third, the dosage of inhaled corticosteroids is
When we take prednisone regularly, the body’s very small compared to the dosage in a pill.
natural production of cortisol is turned off. Taking Inhaled corticosteroids are measured in micro-
prednisone on alternate days allows natural programs, while oral corticosteroids are measured in
duction of cortisol to continue at least on the milligrams. (One thousand micrograms make up
alternate days. 1 milligram.) To give you an example, 400 micro-
grams of an inhaled corticosteroid will have the
Q. What are the potential side effects of same effect on the lungs as 5–10 mg of predni-
prednisone? sone. There is a tremendous difference in the
amount of medication required orally when com-
Prednisone has many potential side effects pared to that taken by the inhaled route. Also,
that affect different systems in the body. These most adverse effects are dose-related. With
include thinning of the bone, growth suppression inhaled corticosteroids, you can take a much
in children, muscular weakness, hypertension lower dose.
Q. Do inhaled corticosteroids have potential Q. What are the long-term effects of corticoste-
side effects? roids on my elderly mother?
Each of us responds differently to medication, You may want to check on eye and bone prob-
so inhaled corticosteroids may have side effects lems. There is some concern, for both pre- and
in some individuals. They are not common with postmenopausal women, that corticosteroids can
inhaled corticosteroids and the most common hasten or worsen osteoporosis. It is for this rea-
one is thrush. This can be minimized by rinsing son that the lowest dose that can control asthma is
your mouth after taking the medication. Studies recommended.
done to date do not show any major side effects
from inhaled corticosteroids. High doses may Q. Will asthma medications affect my sex life?
turn off production of the natural hormone corti-
sol. Cataracts have been seen in older adults on No. Corticosteroids are not anabolic steroids
inhaled corticosteroids. High doses are >800 mcg and do not affect sexual function. In fact, they
for children and >1000 mcg for adults of beclo- may help your sex life. However, do not forget
methasone and equivalent doses of other inhaled that sexual activity is a form of exercise, and it
corticosteroids. could hence cause exercise-induced asthma.
In children on high doses of inhaled cortico-
steroids, there has been a suspicion that growth
may be slowed down. Careful studies have not 13.7 Testing and Devices
shown this to be common problem. Children with
severe asthma, even if they are not on inhaled Q. What is a pulmonary function test?
corticosteroids, will grow more slowly than chil-
dren without asthma. It is a test done in a laboratory that accurately
measures how well your lungs are working. It is
Q. What is the long-term effect of corticosteroids often used to confirm a diagnosis of asthma.
on height?
Q. Can I double-load my Turbuhaler and end up
Initially, corticosteroids have a temporary taking a double dose by accident?
effect on growth. While children on this medica-
tion grow more slowly than their peers, studies No. The Turbuhaler uses a cup-style system.
have shown that the final height they reach is not Little cups (two or three, depending on dosage)
affected by corticosteroids. When using cortico- scrape across a tablet of compressed medication
steroids, the goal is to manage asthma with the when the base of the Turbuhaler is clicked. Once
minimum dose. Asthma that is not controlled will filled, the cups cannot be refilled until they are
suppress growth. emptied. However, the mechanism that keeps
track of the doses advances with each click even
Q. Why can’t my doctor just give me one of those though the medication has not been taken. By
once-a-day pills instead of steroids to control trying to double-load the Turbuhaler, you are
my asthma? actually wasting doses.
Those pills only work for certain kinds of Q. Why do I have to shake my inhaler?
asthma. However, in your case, your healthcare
provider has decided that the best medications to When you shake your inhaler or puffer, you
control your asthma are the inhaled corticoste- ensure that the medication in the canister com-
roids to reduce inflammation and prevent your bines with the propellant so that when you acti-
asthma from getting worse. vate the inhaler, you get a proper dose of
13.8 Spacers 459
medicine. Using the device without shaking it Turbuhaler is empty is by looking for the red flag
may result in you getting too much medication or at the bottom of the window on the side of the
too much propellant—both of which are device.
undesirable.
Q. My puffer does not have a counter. How do I
Q. Why do I need to prime my inhaler before I tell when it is empty?
start using it or if I haven’t used it for a
while? Remove the canister from the holder. Hold it
near your ear and shake it. If you don’t hear any-
In a new inhaler, the valves and tubing through thing, it is empty. It is easier to keep track of your
which the medicine with the propellant emerges medication by doing a little simple math. Check
are empty. They have to be filled before you get a the number of doses shown on the canister, and
proper dose. That’s why priming is needed. If an make a note of the date you started on a new can-
inhaler is not used regularly, the medication ister. Based on the doses you use each day, calcu-
drains out of the valves and tubing, and you need late and write down the date by which it should
to prime the device in order to fill them up again. be empty. For example, if you start a new puffer
today and take 2 doses a day, and there are 60
Q. Why do I have to wait 1 minute between doses in the puffer, then it will be empty in
puffer doses? 30 days from today.
Don’t forget to renew your prescription a few
The mechanism that measures the amount of days before the “empty” date you calculated. Or
medication has to be reset after each activation of stick a label on your puffer and make a small
the puffer. If you click twice in a row, the mecha- mark for every dose you take. That way you will
nism may not have had time to measure the medi- know how many doses you have taken and how
cation for the next dose. You also have to make many are left in the puffer.
sure that the medication is properly mixed with
the propellant. To ensure that both of these things
are done correctly, the manufacturers suggest that 13.8 Spacers
you wait 1 minute between doses, and shake the
inhaler before taking the second dose. Q. What is a spacer?
Q. How do I tell when my Turbuhaler is empty? A spacer is a simple device that makes it easy
to use a puffer. It does this by eliminating the
If you look at your Turbuhaler, you will see a need to coordinate your breathing with the acti-
clear window on one side. A red flag appears at vation of the puffer.
the top of the window when there are 20 doses
left. When the red flag is at the bottom of the win- Q. How do I use a spacer or holding chamber?
dow, the Turbuhaler is empty. It cannot be refilled.
First, shake the puffer. Then place the puffer
Q. My Turbuhaler is supposed to be empty, but I into the end of the spacer/holding chamber. Place
can still hear the medication in it when I the mouthpiece of the spacer/holding chamber in
shake it. your mouth. Release the medication into the
spacer/holding chamber while taking a slow deep
What you actually hear is a desiccant—a pow- breath. Hold your breath for at least 10 seconds
der that keeps the medication dry and prevents it or for as long as you are able. Breathe out.
from clumping. So an empty Turbuhaler will If you are using a holding chamber with a
never sound empty! The only way to tell if your valve, place the mouthpiece in your mouth once
again and take another breath. The holding cham- enough for the mouthpiece of your inhaler, and
ber will hold the medication and allow you to place the mouthpiece in the hole. Place the cup
take this second breath. This is especially helpful over your mouth and nose and activate the inhaler.
for young children. In this situation you would probably be wise to
use the inhaler without a spacer.
Q. What are the advantages of using a spacer?
Q. My healthcare provider suggested that after
It increases the space between the inhaler and cleaning my spacer, I should activate my
your mouth. It allows the large particles to settle puffer into it two or three times. Why do I
in the spacer instead of in your mouth. It reduces need to do that?
the chance of thrush.
There is a lot of static electricity in a new or
Q. What are the advantages of using a holding just-cleaned spacer. Activating your puffer a cou-
chamber with a valve? ple of times reduces the amount of static electric-
ity so that when you need to use your puffer, the
You do not have to coordinate activation of the medication will not stick to the sides of the
inhaler with inhalation. It not only allows the spacer. This ensures that you get a full dose of
large particles to settle inside the chamber, but it medication when you require it. Alternatively,
also allows you to take a second breath. More after washing your spacer or holding chamber
medication gets into your airways and very little with soap and water, allow it to air dry so that no
ends up at the back of your throat. It also reduces static charge builds up inside it.
the chance of thrush.
Q. What are the disadvantages of using a spacer 13.9 The Peak Flow Meter
or a holding chamber?
Q. What is a peak flow meter?
Using them requires an extra step. They may (or)
also be bulky. They require regular cleaning. Q. How does using a peak flow meter help me?
Holding chambers must also be checked to ensure
that the valves are working properly. A peak flow meter is a simple handheld device
that measures how fast you can blow air out of
Q. I don’t like carrying around my large-volume your lungs. It is a simple way of monitoring what
holding chamber. It tends to get broken quite is happening inside your airways.
frequently if I carry it in my backpack. Is When you have an asthma attack, the nar-
there anything else I could use in an rowed airways prevent you from breathing out
emergency? properly. A peak flow meter can tell if your air-
ways are beginning to narrow, and the peak flow
There is little reason to carry a spacer around. reading tells you how well your lungs are
If you are going backpacking in a remote area, functioning.
ask your healthcare provider to review your regi-
men. The Turbuhaler might be best in this situa- Q. I tried a new type of peak flow meter and
tion. Ideally you should use one of the spacer found that instead of blowing 340, I now blow
devices, some of which are quite small. Also, 360 consistently. Why?
they need to be used mainly with inhaled cortico-
steroids which usually only need to be taken once There are slight differences between peak
or twice a day in the privacy of your home. flow meters made by different manufacturers.
In an emergency, use a paper cup. Cut a small There are also differences between meters made
round hole into the bottom of the cup, just big by the same manufacturer. That is why it is
13.10 Allergies 461
important that you use the same device at all Some children call every pain a headache
times so that you can be consistent in judging because they have heard their parents use the
how well or how poorly you are doing. The next word and understand that it means not feeling
time you go to the Emergency Department of a well. Hence when they feel unwell because of
hospital or to see your healthcare provider in a their asthma symptoms, they may inform you
clinic, take your own peak flow meter with you that they have a headache.
so that the readings you obtain remain
consistent. Q. My peak flow readings are always higher in
the evening than in the morning. Is this
Q. My son (aged 15) blows 750 on his peak flow unusual?
meter. He knows he is in trouble when his
peak flow drops to 600. Yet, when he goes to No. This is known as diurnal variation. Peak
the hospital, they say he is fine. flows generally tend to be higher in the evening
than in the morning.
A reading of 600 may look normal to a doc-
tor who does not know that your son normally Q. What is an action plan?
blows 750. When you take your son in, you
must tell the doctors what his normal and per- An action plan or asthma action plan is just
sonal best readings are. Otherwise, if they have that — a set of written instructions that helps you
no idea of what he can actually do, they will go take action to control your asthma. It tells you
by a chart that gives the generally accepted what to do when you have an increase in symp-
range for his age and height. So, it is important toms or when your peak flow readings drop. It
that you take his peak flow chart and peak flow tells you what to do and when to do it so that you
meter with you when you go to Emergency, and can control your asthma.
tell the doctors what his personal best, and nor-
mal, readings are. Q. What kind of information should I record in
However, the peak flow is only one way of my asthma diary?
finding out how someone with asthma is doing. The information you record will help your
Most hospitals will measure heart and respiratory physician adjust or modify your treatment
rate and oxygen saturation. Some will do spirom- program. It should include:
etry, which is more accurate than peak flow. • Any asthma symptoms (or their absence)
• Peak flow readings
Q. My son is 3 years old. If he cannot use a peak • Medications taken
flow meter, how can I tell if he is going to • Changes to the treatment program
have an asthma attack? • Number of times reliever medication is
used
Every person has their own pattern of asthma • Exposures to allergens or triggers
and warning signs that indicate that attack is on
its way. Carefully observe your child before an
attack—this will help you identify warning signs 13.10 Allergies
before your child shows any obvious symptoms.
The warning signs may be simple things like Q. What is an allergy?
scratching his throat or a flushed face or red ears
or itching. He may even complain of tummy pain It is an abnormal response by the body’s
or a headache. Small children cannot tell where immune system to a substance that is not harmful
their chests end and their stomachs begin, and so to most of us. An allergic reaction can occur in
a complaint of tummy pain may be their way of response to even a minute amount of the
indicating tightness in the chest. substance.
Q. I have allergies. Does that mean I have Q. Are food allergies linked to eczema and ear
asthma? infections?
No. They are two separate things. You can Many children with asthma have allergic dis-
have allergies without asthma. In the same way, orders such as eczema that may be connected to
some people can have asthma without having food. Foods that can cause problems include
allergies. cow’s milk, eggs, fish, peanut butter, wheat, tree
nuts, shellfish, and soy. There is no evidence that
Q. What are allergic shiners? a particular food is responsible for ear infections.
Bacterial infections are usually the cause of ear
These are the dark rings that come from con- infections.
gested sinus cavities below the eyes. Inflammation
of the sinus due to allergies causes constriction of Q. I take antihistamines to control my hay fever
the blood flow, and this causes darkening of the in spring. That is also the time when my
area below the eyes. asthma gets bad. Why can’t I increase my
dosage of antihistamines instead of taking
Q. The healthcare provider said my son had an corticosteroids?
allergic crease from the allergic salute. What
was he talking about? Antihistamines work only on allergies. They
are good for controlling the symptoms of an
Children who have allergies tend to develop a allergic reaction or to help prevent an allergic
crease across the middle of their noses because reaction. They do not control the inflammation of
they constantly push the end of their noses the airways, which is asthma.
upward in an attempt to get more air. This is
known as the allergic crease. The hand movement Q. Should everyone with asthma have an allergy
they make when pushing their noses upward is test?
known as the allergic salute. While these terms
sound derogatory, they are in fact accepted medi- Allergy tests can be helpful if the asthma is
cal terms. triggered by allergens. They may be recom-
mended if there is poor response to treatment or
Q. Can allergies trigger an asthma attack or as a supplement to a case history. It can be useful
make asthma worse? in confirming allergies to dogs, cats, dust, grasses,
and pollens, but you should be aware that stan-
A wide range of allergens may act as triggers dard tests are not a reliable way to identify food
for an asthma attack. House dust mites, grasses, allergies.
pollen, pets, and molds are just a few examples.
They can cause low-grade inflammation that by Q. My son gets sick every time he has milk or a
itself leads to few problems. However, when milk product. I know he is allergic to milk but
something else, such as a cold, comes along, the the allergist says he is not allergic to milk
combination can result in an asthma attack. even though he gets really sick. I don’t
understand.
Q. Can antihistamines be taken with asthma
medications? Most people use the term allergic when they
have a reaction to a food. When the allergist talks
Yes, if they are prescribed by your healthcare about allergies, she is talking about a very spe-
provider. However, antihistamines will not help cific event that happens in the body. This did not
asthma. happen with your son. He may not be allergic, but
13.11 School and Camp 463
he likely has an intolerance to milk and that does involves his teachers will go a long way to mak-
mean that he should avoid milk products. ing school a normal and enjoyable experience for
your child.
Q. Will allergy shots help my asthma? It is an unfortunate fact that many schools
have cut back on maintenance to save money.
This is a decision you have to make after talk- The physical environment may have deteriorated
ing with your allergist. It will depend on how with more dust and allergens in the air, together
severe your allergies are and on what your aller- with increased carbon dioxide (CO2) due to poor
gens are. In general, allergy shots are not recom- ventilation. These cutbacks are shortsighted as
mended for people with asthma, and they may the poor physical environment affects learning.
even be potentially dangerous. You should dis-
cuss this with your allergist. If you do take allergy Q. Just the smell of peanuts can cause my child
shots, make sure it is in a clinic or office where to have an asthma attack. Should I ask the
facilities and trained people are available to help school to ban peanuts?
in case of a life-threatening allergic reaction.
You may ask, but whether the school will
Q. Is it safe to use products that are labeled impose a total ban on peanuts is uncertain. The
hypoallergenic if you have allergies? problem lies with the enforcement of the ban.
You may have a better chance if you request a
No. The word “hypoallergenic” was invented peanut-safe environment for your child, rather
in the 1950s by the cosmetics industry to indicate than a peanut ban. For example, you could ask for
that a product was less allergenic, whatever that a “safe room” to be set aside for your child and
means (since no comparison to other substances other children with the same condition, in which
was provided). The term does not mean anything they can eat and where no one is allowed to bring
since there is no standard definition or interpreta- in peanuts or peanut products. This would require
tion for it. It is not a medical word. an adult to supervise lunch. The peanut ban could
also apply to the child’s classroom.
Education (about asthma) of classmates and
13.11 School and Camp school staff and personnel will be helpful. An
epinephrine injector should be available at school
Q. Can my child go to a regular school? Or for use if your child is inadvertently exposed to
should I teach him at home? peanut butter. Trained personnel should be avail-
able to administer the epinephrine injector.
Children with asthma feel different because of
their asthma. Unless you have a compelling rea- Q. Can I send my child with asthma to camp?
son to teach him at home (such as a religious
belief), it is advisable to send your child to a reg- Yes. It is important to remember that your
ular school. child is first a child and, second, a child with
Of course, this requires that you take certain asthma. Treat her like a normal child. You can
precautions. These would include informing the certainly send your child to camp provided the
principal and staff at your child’s school of his camp organizers are aware of her health condi-
health condition. It would also require that you tion and know how to help her avoid his triggers
ensure he has a safe environment in the class- as well as what to do in the event of an attack.
room and that he will not be exposed to his trig- If you take the necessary precautions, your
gers while he attends school. You may need to child should have a wonderful experience with
spend some time at the school teaching the staff other children her age, at camp. If your child has
about asthma in general and how to handle an severe asthma and severe allergies, you may wish
asthma emergency. A cooperative approach that to look into special camps that are run for
children like her. Your local Lung Association when to take the reliever medication before exer-
can help you find a suitable camp. cise. Having to run laps causes problems for chil-
dren with asthma. If the PE teacher allows the
Q. What information should we give our chil- child to sit down if he/she feels asthma is coming
dren’s teachers? on, that would be best.
Give the teachers the following Sometimes teachers are reluctant to take the
information: child’s word, and this may need some discussion
• Persons to contact in an emergency, pref- with the family. If there are concerns about how
erably two names and phone numbers often the child is sitting out or of faking episodes,
• Names and phone numbers of the family these should be discussed with the teacher. If the
healthcare provider and asthma specialist child is frequently unable to participate in physi-
(if any) cal education classes, then the child’s asthma
• The list of asthma triggers, including spe- requires reevaluation by a healthcare provider.
cific food allergies
• A description of your child’s asthma Q. Can asthma affect our child’s performance at
symptoms school?
• A list of your child’s regular asthma med-
ications and their dosage Asthma should not affect the child’s perfor-
• A copy of your child’s asthma action plan mance at school unless he is missing a great deal
• Whether your child is on prednisone or of classroom time or frequent nighttime attacks
being slowly taken off it are leaving him tired and lethargic the next day. If
• An outline of the treatment plan for an your child misses more than a few days each term,
asthma attack his treatment program should be reevaluated.
• The location in the school where addi-
tional medications are kept Q. Our child often coughs in the morning and is
• The steps to be taken in case of a severe often sent home from school because of his
asthma attack asthma.
Do be careful that you don’t become overpro-

Q. What should we tell our child’s teachers tective. Coughing or wheezing at night or in the
about asthma? morning should not be justification for keeping
your child away from school. It does indicate that
Teachers should be informed about the child’s your child’s asthma needs to be reevaluated by
severity of asthma and the possible need for the healthcare provider.
adjustment to exercise. They should be encour- Keeping an extra set of medications at school
aged by the parents to allow the child to have and informing teachers about your child’s asthma
control of his or her asthma and to let the child will ensure that mild attacks can be managed at
decide when to take medication. school so that your child is not sent home
unnecessarily.
Q. How do we deal with a physical education
teacher who accuses our child of faking an
attack to get out of class? 13.12 Pregnancy
Contact the teacher and explain that asthma Q. If I have asthma, can I still take birth control
can vary from day to day. There are days when pills to prevent pregnancy?
the child can participate in exercise and days
when the child will be unable to do so. The child Yes, but do discuss your medication regimen
should be able to decide when to exercise and with your healthcare provider.
13.13 Travel 465
Q. I’m pregnant. Can I take antihistamines? mended because there is a suspicion that codeine
taken during the first trimester can cause abnor-
The effects of antihistamines on the fetus are malities in the fetus. Talk to your healthcare pro-
not known. Hence healthcare providers suggest vider about finding a substitute.
that you avoid antihistamines during pregnancy.
Q. Will my having asthma hurt my baby?
Q. Will the medication I take to control my
asthma during pregnancy affect my baby? I Not if your asthma is controlled. Uncontrolled
think it may be better to stop taking my asthma is associated with preeclampsia, low birth
asthma medications. weight babies, preterm births, and perinatal mor-
tality. When your asthma is controlled, these
Do not stop taking your asthma medications. risks are reduced.
As soon as you know you are pregnant, see your
healthcare provider and discuss the medications Q. How will I know that the baby is okay?
you take to control your asthma. It is extremely
important to keep your asthma under control dur- Your obstetrician or midwife will monitor the
ing pregnancy. fetus to make sure that the baby gains weight, and
A severe asthma attack will affect both you your healthcare provider will monitor your symp-
and the baby. Your baby needs (and uses) the oxy- toms and lung function. This will ensure that both
gen you breathe. You will harm your baby if your you and the baby are doing well.
asthma symptoms prevent it from getting enough
oxygen. Q. Will my baby get asthma?
Q. Will pregnancy make my asthma worse? It is possible—the chances are greater if there
We don’t know! The approximate odds are is a history of asthma and allergy in the family.
as follows: Asthma in children has been linked to low birth
• For one in three women, asthma will not weight and to exposure to smoke in utero.
change. However, keeping your asthma well controlled
• For one in three, the asthma will improve. and minimizing the risk factors may help prevent
• For one in three, the asthma will get the baby from developing asthma.
worse.
Q. Will our next child have asthma, too?
During pregnancy, you should not smoke and
should be very careful to avoid anything that you Having one child with severe asthma does
know worsens your asthma. The asthma medica- not mean your next child will also have severe
tions you are using have all been taken safely asthma. A strong family history of asthma will
during pregnancy, and with care, you will be able increase the risk of any of your children devel-
to keep your use of them to a minimum. oping the condition, but this should not influ-
ence your decision on whether to have another
Q. The healthcare provider said I should not child.
take aspirin because of my asthma. I’m preg-
nant. Tylenol alone doesn’t help my head-
aches. Is it okay to take Tylenol with codeine? 13.13 Travel
Aspirin has been known to trigger asthma in Q. Can people with asthma travel by plane?
some people, and that is why your healthcare pro-
vider suggested you not take it. However, if you There is no reason why you cannot travel by
are in your first trimester, codeine is not recom- plane as long as your asthma is well controlled.
Q. What precautions should I take with my medi- Before travelling to a foreign country, contact
cations when I travel? IAMAT (the International Association for
Medical Assistance to Travelers) for the name
There are many things you can do to make and phone number of a healthcare provider who
your trip safe. speaks your language in each city you intend to
These include: visit. When travelling by air, pack all medications
in carry-on luggage. In the USA, contact:
• Keeping your medications with you at all
times, not locked in your luggage. IAMAT USA
• Making sure that you have sufficient medica- 417 Center Street
tion to last for your entire trip because you Lewiston, NY 14092
may not be able to fill a prescription that is Phone: 716-754-4883
from another state or country. Iamat.org
• Taking a copy of your prescription with you.
• Ensuring that your medication does not get
wet or exposed to high temperatures. High 13.14 Coping
humidity and both extremes of temperature
will affect medication. Q. My child’s healthcare provider suggested we
• Ensuring that all medication has a pharma- get rid of our pet. However, his brothers are
cist’s label on it with the name of the person very upset at the thought of getting rid of our
for whom it is meant. cat. What can I do?
• Keeping your medications together in a clear
plastic bag when going through customs or Pets are family friends. Any decision regard-
airport screening so that they are not handled ing them can be complicated.
by anyone other than yourself. First, getting rid of the cat will help your
• Remembering that some countries will not child’s asthma, but the other children will blame
allow the use of puffers. Talk to your health- him for the loss of their pet. A good compromise
care provider and get your medication in a dif- for the moment is to keep the pet out of his bed-
ferent device. room and make sure that the cat never goes in
there. The bedroom should be a safe place for
Q. What special arrangements do we need to your child.
make for travelling? Second, wash the cat regularly every week, in
order to reduce the amount of dander. And make
Organize your travel plans so you are not too sure that everybody washes their hands after
far from medical help in an emergency. Take touching the cat.
extra supplies of medications and carry them
with you at all times. Always travel in a clean car. Q. Our son complains that his asthma leaves
If it has air filters, they should be clean and in him too tired to do homework.
good condition. There should be no smoking in
the car. Do not travel with pets. Have an emer- Is he really too tired to do homework? Or is he
gency plan in place, and carry documentation using his asthma as an excuse? First, check that
about your condition and medications so that his asthma is well controlled and that his asthma
emergency treatment can be prescribed in another is not disturbing his nighttime rest. If his nights
location. are disturbed, then he needs to see the healthcare
13.14 Coping 467
provider to be reevaluated so that the asthma can Further, lack of an initial reaction does not
be brought under control. mean that you will not develop an allergy to the
animal at a later date. Losing a cherished pet is
Q. Our child has asthma. Should we see a always more upsetting than never having a pet in
counselor? the first place.
Having a child with asthma places severe Q. Will we have to find a new home for the family
stress on the entire family. Parents may feel both pet now that I/we have been diagnosed with
fear and guilt, and these feelings are normal. A asthma?
social worker or psychologist can help the entire
family deal with the added stress of caring for a Animal hair, dander, and saliva will be present
child with asthma before emotional problems in most parts of your house. They are the cause of
make family life unnecessarily difficult. allergic reactions and can make your asthma
worse.
Q. Our 3-year-old has asthma and is rather ram- After you remove the pet from the house, it
bunctious. Should we limit her activities to will take 3 months of regular cleaning before the
prevent coughing and wheezing? pet hair and dander are completely removed.
Is it worth getting rid of the pet and causing
No. Your child should be allowed to lead a full emotional distress? You could try boarding the
and active life. Assessing her condition, identify- pet out for several months to see if your asthma
ing her triggers, and following an appropriate improves, or you could keep the pet out of your
treatment program are the most effective man- bedroom and ensure that everyone washes their
agement strategy. hands after touching the pet.
Q. How do we enforce a no-smoking policy in Q. Our 7-year-old daughter is distraught

our home? because our healthcare provider says she
must not keep any of her stuffed toys in her
Very strictly, because it can be a matter of life room. What can we do?
and death if someone in your home has asthma.
Insist that no one smokes inside the home. Any It is likely that the healthcare provider recom-
family member who smokes and who will not or mended removal of the stuffed toys to reduce her
cannot quit should be asked to smoke outside. exposure to dust mites.
There are a few options you could consider.
Q. I have asthma. I have been around dogs with- For instance, she could keep her favorite stuffed
out any difficulty and want a puppy very toy provided it is regularly cleaned (by washing
badly. Is it safe to buy one? or by placing in a plastic bag in a freezer over-
night and vacuuming the toy thoroughly in the
Once you have been diagnosed with asthma, it morning). The other stuffed toys should be put
is not advisable to buy any pet which has fur or away. Alternatively, the stuffed toys could be
feathers. Doing so could easily add to your prob- rotated so that she has a different one each
lems. While the pet may not trigger an asthma week.
attack, it may serve as on ongoing irritant that If these solutions are not acceptable, clean all
makes attacks triggered by other allergens more the stuffed toys. Buy some large clear plastic
severe. storage boxes with lids. Store the toys in these
boxes in her room so that while she can see them, professional help, if required, will help all mem-
they will not collect dust. bers of the family feel more comfortable about
the asthma and the realities inherent in the
Q. Our child wants a pet, any pet. What kind of condition.
pet is recommended for a child with asthma?
Q. When should a child begin to assume more
Cats, dogs, and birds are not acceptable. While responsibility for his treatment program?
lizards and fish may not be the most exciting pets
in the world, they do not trigger asthma symp- Encourage your child, when young, to take
toms and will not be a long-term irritant. part in monitoring her treatment program. As
your child grows older, she should begin to
Q. The pet store assured us that the pet we want assume more responsibility for her medications.
to purchase is hypoallergenic and will not By the time she is a teenager, your role should be
cause my asthma to get worse. largely supervisory, i.e., of ensuring that she
takes her medications and follows other instruc-
Regretfully, there is no such thing as a hypoal- tions from the healthcare provider.
lergenic pet. The word hypoallergenic is not a Children mature at different rates, so the pro-
medical word. It is used to indicate that some- cess of shifting responsibility to the child should
thing is less allergenic—but less allergenic than be based on the child’s age and maturity.
what? It is a marketing ploy.
Since it is the dander, saliva, and fur/feathers Q. How should we approach the question of
of a pet that are the source of allergen, it would asthma severity? Should we discuss death
have to be a remarkable pet that did not produce with our child?
any of these.
Many parents are afraid to talk about death,
Q. What should we tell our other children when but it is important that children know that death
they say they feel deprived of vacations, pets, from asthma is extremely rare. If they feel that
and other things? they are in control of their bodies, and they know
what to do and are prepared for an asthma attack,
It is important that your other children do not then they will feel more confident and less
feel that they are not as important as your child fearful.
with asthma. They require attention and should
be made to feel special too. Events such as fam- Q. Is it normal for children with asthma to expe-
ily outings and vacations can be carefully rience feelings of anger, frustration, and
planned so problems are minimized. Some sacri- guilt?
fices are inevitable. A pet allergy means no pets, A child with asthma often experiences
even if your children desperately want one. feelings of anger, frustration, and inferiority.
Explain the situation to the children as clearly Typically, this child will say things such as:
and as honestly as possible. Help them under- • Why me?
stand that you are being as fair as you can and • Why do I have to be sick?
that the sacrifices they make are being made for • I feel different.
good reasons.
The other children should not be made to feel These feelings can be overcome by allowing
as though they are responsible for guarding their your child to lead as normal a life as possible. Let
sibling’s health. Open family discussions or your child participate in activities with friends
13.14 Coping 469
and take part in as many activities as possible at Your healthcare provider may be able to adjust
school. the treatment program so that regular medica-
Medications can be taken before sporting tions can be taken when friends are not around. If
events or special outings so that participation in behavior problems persist, consider seeing a
those activities is not denied. Children with counselor.
asthma do not need to be overprotected. With
your help and support, your child should be able Q. Is there more conflict between our teenager
to lead a full and active life. and us because we have difficulty allowing
her to be independent?
Q. It seems our teenager is more dependent on
us because of her asthma, and she feels Many parents have a tendency to be overpro-
resentful. Is this normal? tective about asthma. This can become especially
difficult during adolescence when the teenager is
By the time your child is a teenager, she (or struggling for independence. Encourage your
he) should have assumed responsibility for tak- daughter to take responsibility for the day-to-day
ing her medications and monitoring her prog- management of her asthma. While difficult at
ress. Taking responsibility for the management first, it will benefit both of you and your teenager
program is a big step toward independence. in the long run.
The teenager who depends on her parents for
day-to-day management of her asthma may Q. Our child has an attack whenever she gets
feel insecure and fearful about her condition. upset. Should we give in to her?
Consider whether the dependency is due to
you, the parents, being overly protective. The overall goal of your child’s treatment
Encourage her to assume responsibility for her program is to ensure she leads as normal and
medications and her symptoms diary. This will as healthy a life as possible. This applies to
reassure her and you that she is capable of man- her emotional life as well. Treat your child
aging her treatment program. with asthma as you would a child without
asthma. Give her love and support but employ
Q. How can we help our teenager to be indepen- discipline when the situation warrants it.
dent, responsible, and compliant with the Surrendering to a child’s emotional blackmail
treatment program? will make normal family life very difficult
and, ultimately, will not help her emotional
Teenagers can be difficult to live with and development.
often create a great deal of stress within the fam-
ily. Adolescence is a struggle for independence, Q. What should we tell family, friends, and baby-
and your teenager may feel extra pressure due to sitters about our child’s asthma?
restrictions imposed by the asthma.
Parental pressure often backfires. A teenager Anyone close to your child should be taught
may deliberately forget to take medication as an how to recognize and manage deterioration of
act of rebellion or as a way to receive special asthma. This will help your family, friends, and
attention. Should this nonadherence result in the babysitters to feel more comfortable about
deterioration of the asthma, be supportive but handling any problems that may arise. It will
encourage taking responsibility for behavior. also give you the peace of mind knowing your
Whatever you do, don’t say “We told you so.” child is in knowledgeable hands when you are
This may only breed further animosity. absent.
Q. What about our child’s healthy siblings? Can do what? When? Knowing that there is a plan in
the asthma influence their behavior? place will relieve a lot of anxiety both for the
child with asthma and other family members.
Siblings are often referred to as the forgotten
children in the family. During a crisis, a lot of
attention is focused on the sick child, and it is 13.15 Immunizations
easy to forget about the healthy children who
tend to fade into the background. Q. Should I have a flu shot? I’m an adult with
Siblings, typically, are very frightened that asthma.
their brother or sister might die. They often
feel left out and resentful that they are not get- Yes. The flu shot gives you protection against
ting special attention. They may even feel influenza A, a very severe viral illness that can be
responsible for the illness (by thinking that even more severe in people with chronic lung dis-
they caused it or contributed to it). They may ease. This is the main reason for the flu shot if
even feel guilty that the sibling is ill and they you have asthma. Another reason, but less impor-
are not. tant, is that flu can be a trigger of asthma.
Q. What behaviors could indicate that our child Q. I had the flu shot last year. Why do I need to
should talk to a social worker or get another one this year?
psychologist?
The influenza virus is constantly changing so
Your child or the child’s sibling may need to that the vaccine has to be “redesigned” every
see a psychologist or social worker if they have year. If you have severe asthma, a yearly flu shot
real fears through the night, have trouble sleep- is recommended.
ing, or have real regression in their behavior. A
visit is also suggested if there are problems with Q. Should every child with asthma have a flu
adherence. shot?
Q. Can you suggest strategies for reducing the Yes. It is recommended for all children with
stresses involved in having a child with a asthma. However, there are always exceptions,
chronic illness? especially if a child has some kinds of allergies.
Talk to your allergy specialist.
It can be overwhelming trying to deal with an
acute episode. Try not to shoulder all the respon- Q. Our son has a life-threatening allergy to eggs.
sibility on your own. Involve the whole family. Can he have a flu shot?
Get everyone involved in learning about asthma
so that they do not feel left out but can share the Children who have a life-threatening (anaphy-
responsibility. lactic) reaction to eggs rarely experience a simi-
Talk about asthma. Often parents, in trying to lar type of reaction to “killed” influenza vaccines.
keep things as normal as possible, do not talk However, to be on the safe side, consult an allergy
with other family members about their concerns specialist.
and about what is happening. These things do
not remain a secret and merely add to the anxiety Q. Can our child be immunized while she is tak-
of all family members. Sit down with the whole ing asthma medications?
family. Talk about asthma, what it is, what is
happening, and above all plan for illness or a Your child should have all routine childhood
hospital stay. How will the family continue to immunizations. These include diphtheria,
function during a health emergency? Who will whooping cough, polio, tetanus, measles,
mumps, and meningitis vaccines. Regular paring apples and oranges. Asthma is a disease in
asthma medications will not affect these immu- its own right. Emphysema describes changes in
nizations. However, if your child is on a short the lungs that can happen for many reasons. In
treatment of oral steroids such as prednisone, emphysema, the air sacs are stretched or
you must consult your healthcare provider before destroyed. Emphysema is often the result of
giving the immunization. smoking.
Q. I have asthma. Is it safe to have the COVID-19 Q. Will asthma give me lung cancer?
vaccine?
No. There is no connection between asthma
Yes. But you should also be wearing a mask, and lung cancer. However, if you smoke, you will
practicing social distancing, and avoiding be a very good candidate for lung cancer.
crowded areas. You should continue these behav-
iors even after you get the vaccine Q. Was it something I did that caused my child to
have asthma?
Q. How does COVID-19 affect asthma? Does it
make asthma worse? The tendency to asthma is inherited, and expo-
sure to a pet or tobacco smoke may have trig-
In the early period of the pandemic, COVID gered the asthma, but there is no point in feeling
was thought have a poorer outcome in those with guilty. That will not help. It is more important
asthma. More recent evidence has cast doubt on now to reduce exposure to triggers and to manage
that conclusion. the asthma.
Q. Does asthma cause lung damage?

13.16 Other Questions
Yes, if left untreated.
Q. Are asthma attacks related to menstrual
cycles? Q. Will untreated asthma lead to pneumonia?
Some females have specific deterioration in No. Pneumonia is the result of a bacterial or
their asthma that is related to menstruation. This viral infection.
is related to hormone fluctuations, especially pro-
gesterone. It is particularly marked immediately Q. When are antibiotics prescribed?
before the period starts. Using a peak flow diary
and marking the days of menstruation will help Antibiotics are prescribed for infections such
clarify any association. as pneumonia, ear infections, or sinusitis. They
are not useful for asthma, since asthma is not
Q. Will my asthma medication affect my induced by bacteria. Antibiotics are only useful
periods? for bacterial infections and will not help reduce
inflammation in the airways. Sinusitis is com-
No. The corticosteroids used in asthma are not mon in people with allergic nasal problems, and
the same as the anabolic steroids or the steroids sometimes when the sinusitis is treated with
in birth control pills. antibiotics, the asthma improves.
Q. If I have asthma, will I get emphysema? Q. Would a change of climate help my asthma?
It is unlikely, unless there are other factors. Generally, no. This is a widely held belief for
Comparing asthma and emphysema is like com- which, unfortunately, there is no scientific proof.
When they go to a new part of the country, people an attack. That will lessen the fear and increase
may feel good for a while until they discover new their feeling of self-confidence.
triggers in the new environment that will affect
their asthma. Q. My child is so frightened of having another
Once you have developed allergic tendencies, asthma attack. What can I do to help
you do not change. Changing your environment her?
may not help your asthma.
Talk about the attack and how she felt. Did she
Q. How can relaxation exercises help my fear that she was going to die? Talking about
asthma? fears can help your child face the fear and lessen
it. Take all the time she needs to talk about her
Relaxation exercises help you to relax in a feelings.
general way. When this happens, there is a feel- Then tell her that you and she will take all the
ing of being in control of the asthma. This means necessary measures to prevent an attack, but if
that the panic that often goes with asthma deteri- one should happen, reassure her that there are
oration is avoided and recovery is faster and medications that can help her, so she does not
smoother. need to feel frightened.
Further, when your muscles are relaxed, it is
easier for the medication to help them relax than Q. Where can I get more information on asthma
when the muscles are very tight. and allergies?
Q. Can a psychologist help my asthma? You can join a local support group. Check
your phone book or with your local Lung
If you require an understanding of the illness Association or hospital.
and need to accept the illness in a way that makes
you feel self-confident, have good self-esteem, Q. Is there somewhere I can get more informa-
and a positive outlook on life, then a psychologist tion on asthma?
can help. Yes, you can contact these organizations:
• The Allergy Asthma Foundation of
Q. Do all children with asthma need to see a America
psychologist? Phone: (800) 7ASTHMA
www.aafa.org
Only those children who are having diffi- • Your local Lung Association
culty coping and understanding their asthma, • Local support groups
those who have difficulty in complying with
medication, or those who express different Q. We often hear that there are treatments avail-
fears in different areas should see a able that will cure or prevent asthma. Will
psychologist. they help?
Q. What is the biggest fear for a child with There are many dedicated individuals who
asthma? have approaches to asthma that are not well
understood by healthcare providers, nurses,
A lot of children are afraid that they are going and pharmacists. It can be difficult to prove
to die. Many parents are afraid to talk about that any particular treatment (regular or
death, but it is important that children know that complementary) will help asthma. There are
deaths from asthma are rare. many reasons for this difficulty. One is that
Children must feel that they have control over asthma can change quickly with or without
their bodies and that they know what to do during treatment!
If you wish to try another treatment, observe • If using herbs, find out the exact contents and
the following common-sense guidelines: ask about the cost.
• Discuss with your healthcare provider how
• Do not stop regular treatment without discuss- you can monitor your progress.
ing it with your healthcare provider. • Remember that avoidance of harmful triggers
• Find out as much as you can about the alterna- is still essential.
tive treatment.
Part III
The Effective Asthma Educator
Learning: Theories and Principles
14
Contents
14.1.1 How Is Learning Achieved? 479
14.2 Learning and Teaching Definitions 479
14.2.1 Learning 479
14.2.2 Teaching 479
14.3 The Learning Process 479
14.4 Theories of Learning 480
14.4.1 Behaviorism 480
14.4.1.1 Relevance of Behavioral Theory to Asthma Education 483
14.4.2 Gestalt or the Cognitive Theory of Learning 483
14.4.2.1 Relevance of Gestalt Theory to Asthma Education 486
14.4.3 The Humanistic Theory 486
14.4.3.1 Relevance of Humanistic Theory to Asthma Education 488
14.4.4 Information Processing 488
14.4.4.1 Relevance of Information Theory to Asthma Education 491
14.5 Online Learning: Some Considerations 491
14.6 Personality Development 493
14.6.1 Infancy: Trust Versus Mistrust 493
14.6.2 Early Childhood: Autonomy Versus Shame and Doubt 493
14.6.3 Middle Childhood: Initiative Versus Guilt 494
14.6.4 Elementary School Age: Accomplishment Versus Inferiority 494
14.6.5 Adolescence: Identity Versus Confusion 494
14.6.6 Young Adulthood: Intimacy Versus Isolation 494
14.6.7 Adulthood: Generativity Versus Stagnation 494
14.6.8 Old Age: Integrity Versus Despair 494
14.6.9 Application of Theories to Asthma Education 495
14.7 Age-Related Learning 496
14.7.1 Learning Styles 496
14.7.2 Children 497
14.7.3 Adolescents 497
14.7.4 Adults 498
14.7.5 Older Adults 499
14.7.6 Implication of Learning Styles 499
14.7.7 Types of Learning 502
478 14 Learning: Theories and Principles
14.8 Barriers to Learning 503

14.8.1 Environment 503
14.8.2 Physical Factors 504
14.8.3 Individual Factors 504
14.8.4 Sociological and Emotional Factors 506
14.9 Principles of Learning 508
References 512
Key Points Chapter Objectives

• Learning and teaching are defined and After reading this chapter, you should be
an explanation of the learning process is able to:
given.
• Each of the theories of learning—behav- 1. Compare and contrast the different the-
iorism, gestalt, humanist, and information ories of learning and their application in
processing—with their applicable rele- the process of teaching.
vance to asthma education is discussed. 2. List the problems and strategies for

• The effects of online learning that dealing with learners of different ages.
emphasize disparities is considered. 3. Identify the barriers to learning and list
• The changes in personality as individu- the principles of learning.
als age are explained together with the
application of these theories to learning
at each age level.
• Learning styles change with age and this At the simplest level, we learn for many rea-
too has implications for the asthma edu- sons—to survive, to get better jobs, to know
cator. The different types of learning are about the world, and so on. And how we learn
discussed. depends on who we are, where we are, and a
• Various barriers to learning include the number of other factors.
environment, physical, individual, soci- For the last 150 years or so, learning theorists
ological, and emotional factors. have devised explanations that attempt to answer
Psychosocial issues and individual fac- those two questions. Each explanation is an
tors of literacy, culture, race, and gender attempt to understand the process of learning—of
are explored. how the mind learns. Each theory has its merits,
• The principles underlying and the tech- but none can be used in isolation or can fully
niques to foster learning are explain how people learn.
enumerated. In other words, human learning remains a
complex process that is not yet fully understood.
The effective asthma educator should have a
basic (but not necessarily detailed) understanding
14.1 Introduction of the various theories of learning, because they
will help to improve the teaching process. This
Why do we learn? How do we learn? chapter attempts to provide that knowledge through
To be successful, every educator must have an a brief and highly condensed description of current
understanding of the answers to those two seem- learning theories. (More detailed descriptions may
ingly simple (but difficult-to-answer) questions. be found in books available at almost any library.)
14.3 The Learning Process 479
14.1.1 How Is Learning Achieved? into knowledge. This new knowledge can then
be applied and can also be used for personal or
For the asthma educator, teaching and learning other benefit, for example, to help control
go hand in hand. The educator must teach, and asthma. It is now a skill. This then is the goal of
the “learner” must be helped to learn and under- asthma education.
stand. If learning and understanding do not occur,
then the teaching process has not been success-
ful, and the asthma educator has failed. 14.2.2 Teaching
Each person has a unique approach to learn-
ing, and these distinct ways are called “learning Education is planned with the intention of help-
styles.” There are patterns of learning styles, just ing an individual learn. Education involves teach-
as there are patterns of asthma. ing with the outcome clearly achieved in a change
To be effective, the asthma educator must: of behavior. Teaching is a process whereby an
educator presents information to a person in such
• Know what a person needs in the way of a way that the person is able to utilize the infor-
asthma information. mation. Since no two people are alike or think
• Know (and understand) the individual’s alike, this also means that the educator must be
unique learning style. prepared to adjust or modify the teaching process
to suit the needs of each person. But more than
Since each person is different, this means that anything, to be effective, teaching must lead to a
the educator must customize or adapt a teaching change in behavior.
program to suit the unique medical needs of the Both these definitions are incomplete and
individual and their distinct learning style. oversimplified. But they will serve as a starting
point for an overview of the learning process.
14.2 Learning and Teaching

Definitions 14.3 The Learning Process
Just as with a definition for asthma, it can be sur- The process of learning begins when a person
prisingly difficult to define learning and experiences new data—something that she or he
teaching! sees, hears, tastes, smells, reads, or actually expe-
riences through touch or through a combination
of senses. The raw data enters the brain, which
14.2.1 Learning then has to make sense of it—to analyze it, under-
stand it, and then store it in such a way that it can
Learning has been described as a behavior nec- be used as needed later on. The steps involved in
essary for living or as the possession of knowl- learning are shown in Fig. 14.1.
edge by experience, by study, or by being taught. The simplest way to appreciate new data is by
It is also considered a biological process essen- relating or connecting it to what is already known.
tial for survival. Learning is difficult to define This is what the brain does: it examines the new
with precision, for it is all of these and more. data, looking for similarities to previous experi-
From the educator’s point of view, learning is a ences the person has had or things the person has
mental process through which a person accepts already learned.
new information and then examines, under- Two outcomes are possible from this analysis:
stands, and assimilates that information. By so either the data is unique (a genuine “new” experi-
doing, the person transforms the information ence), or it can be related, either vaguely or
Fig. 14.1 The Learning Process. (© The Asthma Education Clinic Ltd)
strongly, to some item or items of knowledge the ronment in the learning process. Then came the
person already possesses. In the latter case, the humanists, who claimed that while all the other
new information is stored in the brain and linked elements were important, none was as important
to those other related pieces of information as the learner himself. That led to the information
already there; in the former case, the information processing theorists, who used a computerlike
about the new experience is stored by itself, since model of the brain in an attempt to understand
it cannot readily be associated with prior how the mind functions, where and why learning
knowledge. takes place, and how the mind stores and retrieves
In both cases, however, the newly acquired information.
knowledge is now available to the brain, to be Today all four theories have their proponents.
used and manipulated for its benefit. The knowl- And, as is so often the case with theories, each
edge can either be used alone or in conjunction possesses some truth. The good educator uses
with prior knowledge to produce new behaviors elements from all of them in order to be an effec-
or actions—a higher form of manipulation than tive teacher.
possible if the “new” knowledge were used by
itself.
This is a simplistic view of the learning pro- 14.4 Theories of Learning
cess based on the theories of learning.
Psychologists have tried to understand and item- Let us briefly consider these four contemporary
ize how learning occurs, but while the outcomes theories of learning [1].
are quantifiable, the actual process is not, hence
the different theories of learning.
Learning theories can be classified into four 14.4.1 Behaviorism
groups: those of the behaviorists, the gestalts, the
humanists, and the advocates of information pro- Behaviorism [2], which attempts to understand
cessing theory. The behaviorists, who came first, why people behave as they do, is based on the
postulated that learning took place as a result of a idea that every stimulus elicits a response. Among
stimulus. They were followed by the gestalt the first to define this relationship was Ivan
theorists who stressed the importance of the envi- Pavlov. He was followed by noted theorists such
as Thorndike, Hull, Guthrie, and Skinner, each of attempt, the level of randomness decreases as the
whom expanded or expressed a different version resolution or goal gets closer. Each response to a
of the basic theory. specific stimulus establishes neural connections
Pavlov (1849–1936) believed that the between the stimulus and the most acceptable
stimulus-response relationship was the basis for responses. Thorndike suggested that learning was
learning. He noticed that his dog salivated just a process whereby physical and mental compo-
before it was given meat. He wondered whether nents were connected in different combinations,
he could make the dog associate the sound of a producing changes in the nervous system.
buzzer or metronome with feeding time and Thorndike also defined the Law of Effect
thereby get the dog to salivate at a specific sound, which states that positive reinforcement strength-
even if there was no meat in sight. His hypothesis ens the mental connections between stimulus and
proved to be correct, but only for a while: in due response and is essential for repetition of a behav-
time, if he produced the sound but no longer gave ior, while behavior that is followed by a negative
the dog meat, the dog no longer salivated. reaction is soon forgotten or terminated [3, 4].
In Pavlov’s experiment, the sound was the Thus, the time needed to learn something can be
stimulus that caused the dog to respond by sali- reduced with positive reinforcement. When
vating. He described this elicitation of a particu- behavior is followed by satisfactory results, the
lar response to a stimulus as “conditioning,” with behavior then becomes an established pattern.
the particular sound described as a “conditioned Rewards for appropriate behavior serve to
stimulus” and the resulting salivation as the “con- strengthen the connection, while punishments for
ditioned response.” Initially the dog learned that inappropriate responses merely serve to weaken
the particular sound meant food and, as a result, but not destroy the association between the stim-
salivated; later, when Pavlov merely produced ulus and the incorrect response. Thus, punish-
the sound but withheld the meat, the dog learned ment is a less powerful method to discourage
that the particular sound did not necessarily mean unwanted behavior than reinforcement to encour-
food and stopped salivating. This was an exten- age desired behavior.
sion of the original conditioning. The basic S-R arrangement is considered
Many behavioral theories are based on this unmediated. When the individual affects the
stimulus-response (or S-R) mechanism. Edward response, the response is deemed mediated.
Thorndike (1874–1949), who expanded on Hence some consideration must be given to the
Pavlov’s theory, hypothesized that learning individual when devising a stimulus in order to
occurs when a person feels the need to react in obtain the required response.
response to some sensory perception. The sen- Thorndike strongly advocated the importance
sory perception results in the urge to act. In other of both practice and reinforcement in learning.
words, a stimulus generates a response. This He was followed by other behavioral psycholo-
approach to S-R theory has also been called con- gists, notable among them Edwin Guthrie (1886–
nectionism. Its dominant belief is that learning 1959), Clark Hull (1884–1952), and B.F. Skinner
can be explained without reference to the internal (1904–1990), all of whom based their theories on
state of the learner. the S-R model.
Thorndike believed that the most common Guthrie believed that learning occurred imme-
method of learning was through the process of diately when the S-R connection was made, and
trial and error. When faced with a problem, peo- hence reinforcement was unnecessary. As long as
ple try different responses and choose the one connections continued to be made, learning
that will either resolve the problem or take them advanced, with the strength or advancement in
closer to a solution. Under this hypothesis, behav- learning being related to the number of connec-
ior remains variable and random until the prob- tions or responses. More is definitely better.
lem is resolved or a goal met. The initial response Guthrie defined this pairing of stimulus and
may be totally random, but with each successive response as essential to learning. Some degree of
learning takes place at every trial and is linked Skinner went even further. To him, learning
specifically to the situation that generated the was a “function of change in apparent behavior.”
response. When a number of stimuli are linked He believed in spontaneous or “operant” condi-
together in this way, then if the stimuli reoccur, tioning in which behavior is rewarded through
the response will follow too. either reinforcement or punishment. Behavior is
Responses are the raw materials for the learn- affected by the response that follows. Behavior
ing process. When learning appears to be slow, it that is rewarded increases in frequency, while
is due to the environment or context in which it behavior that is not rewarded decreases in fre-
occurs. This context is complex and in a state of quency. Thus, rewards become important to the
constant change. Teaching or instruction must individual learner. Further, the type of reinforce-
hence present a sequence of specific tasks, taking ment provided determines the consequent
into account the context, since learning involves behavior.
the conditioning of specific movements. Skinner’s theory also required that learning be
Guthrie is noted for his declaration that data divided into small portions and questions on each
on learning should be based on what is observ- portion arranged according to difficulty. Since
able, and not on the learner’s reports. Learning easy questions were presented first, the probabil-
should be measured in terms of behavior and ity of a correct response by the learner would be
bodily changes. This was a radical and ground- increased, thereby providing positive reinforce-
breaking approach, because it moved assessment ment. This was the first formulation of the con-
of learning from the realm of self-evaluation to cept underlying the “programmed instruction
external, perceived, and measurable behavior, units” used in teaching machines and in today’s
which is the only true measure of successful computer-based training courses. Here response
teaching. is modified by rewards. Inappropriate responses
Clark Hull stressed that the internal state of are not rewarded, thereby promoting a change in
the learner (the emotional and other needs) the learner’s behavior.
affected the S-R connection. The underlying This was behavior modification or behavioral
basis for Hull’s work was his belief that the S-R engineering through change or adaptation of the
connection depends on both the kind and the environment in order to attain a desired behavior
amount of reinforcement. Behaviors that satis- [5]. The learner worked at his or her own pace
fied internal drives or needs were reinforced and, and was rewarded for correct responses. The
as a result, were repeated willingly, so that mini- reward acted as reinforcement for the learning
mal reinforcement was required for the repeti- that had occurred. It was necessary that both the
tion of a behavior. In other words, conditioning teacher and the learner know the goal and that
took place only if the learner was attentive, both conduct frequent evaluations to determine
wanted something, was active, and saw the progress and provide motivation.
action as satisfying a particular need. Habits, Unlike his predecessors, Skinner believed that
based on rewards for S-R connections, were thus the learner could emit a response instead of
formed and were a direct function of practice. responding only to an external stimulus. That
While responses are necessary ingredients in the meant that reinforcement could be in the form of
formation of habits, the process of habit forma- satisfaction at a job completed or even a sense of
tion is gradual, with the reward being an essen- accomplishment. It need not be external in the
tial condition. Reward or reinforcement is form of verbal praise and a good grade, which are
necessary for learning. considered secondary reinforcers.
Hull’s theory is defined as the S-O-R model Skinner’s approach promoted behavioral
where Stimulus is affected by the Organism (the modification through adaptation of the environ-
learner) and determines the Response. Learning ment to attain a desired behavior. Though he
can only take place when both the stimulus and repudiated the theories of learning, the fact
response is apparent to the learner. remains that his ideas on operant conditioning or
behavior modification continue to be used in clin- Table 14.1 A summary of Behavioural Theories
ical settings, in classrooms, and in the design of Behavioral theories
programmed instruction material. Pavlov Learning is stimulus-response (S-R)
sequence
Thorndike Learning is trial and error
14.4.1.1 Relevance of Behavioral Law of Effect
Theory to Asthma Education Practice and reinforcement strengthen S-R
The behaviorists believe that a stimulus generates Guthrie Reinforcement is essential while S-R
a response by the learner. The response is part of connections are made
Learning is measured by observable
the behavior of the learner, and the consequences
behavior
either reinforce or terminate the behavior. Thus Hull Organism affects response. S-O-R
behavior where the consequences are positive is Organism’s needs define the response
reinforced and will be repeated. If the conse- Skinner Operant behavior can be controlled by
quences are unpleasant, the behavior is not chosen stimuli
Graduated questions provide
repeated. Reinforcement can come from within self-reinforcement
the learner or from without. For example, a per-
son who tries relaxation exercises during an
asthma exacerbation, and then realizes that they becomes more stable and predictable, the rein-
actually help reduce its severity, will be more forcement can become intermittent.
likely to try relaxation techniques at the first sign The behavioral theories (see Table 14.1)
of another. This is self-reinforcement. describe a mechanistic and linear approach to
Reinforcement has to be immediate and con- learning that minimizes the role played by per-
sistent. Immediate reinforcement strengthens the sonal motivation and purpose. In effect, the
behavior. Individuals with asthma who obtain behaviorists believe that a person can learn any-
relief from bronchodilators will not hesitate to thing if willing to proceed through a predeter-
use them when they require relief from symp- mined pattern of activity. Central to behavioral
toms. Similarly, if they expect immediate relief tenets is the concept of changed behavior that is
from an inhaled corticosteroid and do not receive brought about by some form of conditioning and
it, they will most likely consider the medication which results in learning.
ineffective. In such cases, the educator must For the asthma educator, it is important to note
explain the role of inhaled corticosteroids and the that:
time needed for them to become effective. If the
individual with asthma does not obtain a direct • Reinforcement is essential for learning.
benefit from a specific behavior, then they will • Teaching should present a sequence of spe-
not repeat the action. Reinforcement that is inter- cific tasks.
mittent will result in the discontinuance of the • Learning should be divided into small
behavior. Behavior that is not reinforced and does portions.
not meet a biological need will be curtailed. • Learning should satisfy a particular need.
These ideas are important for teaching pur- • Teaching is changing behavior.
poses in that learning requires reinforcement • Learning takes time.
especially since teaching is defined as “causing a • Learning is measured in changes in behavior.
change in behavior.” The teacher controls and
directs the learning and is responsible for the
learning. The teacher defines the objective and 14.4.2 Gestalt or the Cognitive
provides the stimulus whose response is the Theory of Learning
desired behavior. When the desired behavior is
achieved, reinforcement is immediately supplied. Called gestalt, meaning shape, form, or configu-
This is repeated until such time as the behavior is ration, this school of psychology originated in
a conditioned response. Then, as the behavior Germany. It states that any experience is felt as a
whole and not as a group of distinct and separate changes his understanding of the milieu and
elements. Hence: affects his thinking processes.
• Motivation can be positive or negative in any
• The entire or whole experience cannot be ana- aspect, even emotional. It may come from
lyzed in terms of its specific parts, for the within or from an outside source.
whole is deemed greater than the sum of its • Ideology deals with the individual’s percep-
parts. tion of himself as a member of a group. It is
• Analysis of the specific elements or integrated this sense of belonging that allows the indi-
structures will not provide an understanding vidual to define himself in relation to a group.
of the entire event. • Dexterity, also defined as control of muscula-
• An experience cannot be analyzed by dividing ture, is related to skill development which, in
it into components or parts, because the turn, affects perception and the initial cogni-
response of an organism is complete and tive change.
hence cannot be analyzed.
Lewin believed that behavior was a function
Behavior, then, is more than a conditioned of perception at the moment that the behavior
response. occurs. In effect, the learner responds according
In this theory, the individual sees meaning and to how he or she perceives the problem at that
structure in his or her environment and has the particular moment in time when the problem is
ability to organize the stimuli in the environment. presented. As perception changes, as a result of
This recognition leads to a cycle of perceptual interaction with the social and physical environ-
reorganization, with problems being solved as ment, so does the thinking change, and that, in
the individual’s perceptions change. turn, affects behavior. Changes in the environ-
Each person sees the world differently, and ment will lead to changes in perception. This, in
that perception may not be totally realistic. turn, is influenced by personal motivation, what-
However, each person’s ability to learn is based ever the source.
on a personal, particular perception of the context All these factors—environment, motivation,
within which he or she resides. Perception is an and change—combine to change the individual’s
active, dynamic, and constructive process. It is perception of himself in relation to others. This
not passive or reflexive as the behaviorists sug- too provides further motivation to perform or not
gest. Perception is affected by environment, past to perform some behavior. Behavior that is
and present, as well as the sum total of past expe- acceptable to the group with which the individual
riences, interests, and concerns. identifies will be strongly reinforced by the group
Therefore, both the learner and the context are so that the individual is more likely to repeat that
important for learning. While the individual’s behavior rather than one that is frowned upon by
perceptions may not parallel reality, they will the group.
influence the learning process. Perception, aware- Lewin recognized that multiple factors affect
ness, and understanding (but not actuality) will learning and that learning was so much more than
affect learning. a simple S-R response. It is affected not only by
Among the more important gestalt theorists the individual and the stimulus but also the envi-
was Kurt Lewin (1890–1947), who defined learn- ronment in which it occurs.
ing as change occurring in the four different cat- Edward Tolman (1886–1959) took the gestalt
egories of cognition, motivation, ideology, and view further by combining the behavioristic and
dexterity: cognitive theories of learning into what is called
“purposive behaviorism.” He suggested that
• Changes in perception of the environment while learning was part trial and error, and part
result in changes in cognition. The way the reflex, there was also something more. Learning,
individual perceives the environment both to him, combined both observable and non-
observable ingredients within which behavior disparate and distinct items. (A child who has not
was observable but the cognitive operation was come to this understanding will cover his eyes
not. and assume that since he cannot see you, you
Tolman believed that learning was a gradual cannot see him.) By the end of this stage, the
process that depended entirely on the succession child realizes that he is a separate physical entity.
of events. The learner produced specific responses
knowing that they would in time generate certain Second stage (2–7 years) This is divided into
circumstances. He suggested that the learner two phases, the preoperational phase (2–4 years)
developed expectations based on experience and and the intuitive phase (4–7 years). In the first
that all learning depended entirely on the phase, the child begins to verbalize and to use
sequence of events. He believed in an introspec- language and symbols. However, the concept of
tive approach that accounted for the learner’s time is vague, and the child has a strong tendency
sensory impressions and perceptions. to adapt and change information to fit in with
Tolman also believed that learning was a more existing ideas. The child is given to fantasizing.
active form of information processing than mere He can perform a series of actions but is unable to
response to a stimulus and emphasized the role of think them through prior to actual performance.
motivation. He suggested that the unit of behav- Imagery is strongly related to concrete elements.
ior is a complete and goal-directed act deter- The child’s viewpoint is self-centered.
mined by a purpose, guided by a cognitive
process and organized by various muscular In the intuitive phase (4–7 years), the child is
movements. That is, the learner decides on a able to work with the concept of number. He
goal, determines how to attain it, and then does begins to understand logical relationships of
so. Learning is hence always goal-directed and increasing complexity. He also begins to catego-
uses environmental factors to select the shortest rize things and appreciate the principle of conser-
and easiest path to the goal. vation—for instance, he begins to realize that
Jean Piaget (1896–1980) greatly advanced the when an item is divided into a number of pieces,
gestalt approach by defining the ages of intellec- its total weight does not change. Envisioning or
tual development. He analyzed the thinking/rea- foreseeing consequences remains difficult. The
soning process of young children and showed child learns how to manipulate the environment
that age was a factor in intellectual development. symbolically through thinking about the external
He found that their minds evolve through pre- world.
defined and set steps as they move toward adult-
hood. In his view, the child is in an unending Concrete operations stage (7–11 years) This
process of creating and recreating a personal stage sees the beginning of abstract thinking and
model of reality. The child attains mental growth of logical thought processes. Objects are classi-
by incorporating simple concepts into more com- fied by their similarities or their differences.
plex concepts at each stage of development. Physical manipulation is succeeded by conceptu-
Piaget defined the four stages of genetically alization, and thinking grows increasingly
determined intellectual growth [4] as follows: abstract. The child attempts to see situations from
the viewpoint of those closely related to him.
Sensorimotor stage (0–2 years) Here, the child There is a growing awareness of consequences.
learns about himself and his environment through Judgment becomes more rational.
motor and reflex actions. Coordination develops
between the eye and hand. Mastery of physical Formal operations stage (>11 years) Reasoning
reflexes extends into satisfactory and pleasurable moves from the practical into the realm of the
actions. Sensory input and movement help the abstract, and the child now performs deductive
child realize that things exist even when they are reasoning and hypothesizes. The child begins to
not in his field of vision and that objects exist as regard ideas and concepts from different perspec-
tives and sees the implications of his own think- • Learning is goal-directed.
ing. Thinking is ordered. Mastery is achieved • Knowledge must be organized for teaching
over logical thinking so that flexibility enters into and learning to occur.
mental experimentation. Abstract ideas are • Age is a factor in intellectual development.
manipulated. • Intellectual age and chronological age may
differ.
It is important to recognize that intellectual
age and chronological age may differ. By going
through these stages, children learn how to think 14.4.3 The Humanistic Theory
logically and draw valid conclusions. Each stage
has to be experienced in its entirety before the The humanistic approach places the learner at the
child can proceed to the next stage. Intellectual very heart of the learning process. It requires an
growth is initiated by interaction with objects in understanding of the learner and the learner’s
the environment. Gradually, ideas are conceptu- needs. It concerns the achievements and interests
alized, and learning takes place through both of the learner. It does not view the learner as a
assimilation and accommodation. Both thinking creature whose behavior is a response to a stimu-
and learning are dynamic processes. lus, conditioned or otherwise. While the learner’s
For learning to take place, knowledge must be developmental history is important, the humanistic
organized. When exposed to new ideas, the approach states that the current environment and
learner first tries to connect them to previous previous experiences have a major role to play.
experience. Piaget called this process “assimila- The humanistic approach states that there is an
tion.” When the new ideas could not be related to innate desire in every individual to achieve “self-
previous learning, he termed the process “accom- actualization” or to develop oneself to the great-
modation.” Accommodation is considerably est extent possible and that it is this desire that
more difficult and often occurs when an idea is motivates all human behavior. Thus, the individ-
totally new, cannot be related to past experiences, ual’s awareness of his present environment
or requires the abandonment of previously held becomes a factor in the self-actualization pro-
beliefs or concepts. Accommodation demands cess. Every individual has certain needs, and all
reexamination of the terms of reference, a change these needs—psychological, emotional, and bio-
in former beliefs, and an adjustment in thinking. logical—must be met before the need for self-
actualization can be filled.
14.4.2.1 Relevance of Gestalt Theory The humanistic view of people tends to be
to Asthma Education comprehensive, to see each person as more than a
The gestalt school emphasized the role played by compilation of mental and biological connec-
environment. Learning was seen as a response to tions. Instead, each person is a thinking, feeling
the environment but also dependent on the learn- individual whose behavior is not solely deter-
er’s motivation. The school’s emphasis on learn- mined by earlier experiences. Each person is
ers’ perception is important, for though two unique and has tremendous potential. Every indi-
people may have the same experience, the per- vidual is responsible for his or her own life and
ception of each will differ depending on individ- actions and can change both behavior and atti-
ual past experiences. No two people will react in tudes through awareness and will. Learning
an identical way to an identical situation. results from a yearning to develop one’s full
For the asthma educator, the following points potential. Learning should be self-motivated
are noteworthy: because the learner should discover a personal
meaning for the required learning.
• Learning is a gradual process. Among the humanists, Carl Rogers (1902–
• The learner develops expectations based on 1987) [6, 7] presented the “client-centered”
past experiences. approach where the learner determined the
course, speed, and duration of learning. The • Overt (expressed by behavior) or covert
learner decided how much would be learned and (expressed in thinking and daydreaming)
how much time was needed to learn it. • Focal (aimed at one goal) or diffuse (satisfied
Rogers classified learning into two compo- by a wide array of goals)
nents: cognitive and experiential. The former was • Proactive (prompted from within the individ-
meaningless and academic, while the latter was ual) or reactive (caused by the environment)
significant because it was experience-based and • Effect (aimed at attaining a goal) and model
hence applicable. The distinction comes from (performed with expertise)
addressing the needs and wants of the learner.
Personal change and intellectual growth are Further, the learner’s relationship with the
dependent on experiential learning. physical and social environment has an impact on
In order to facilitate experiential learning, the learning. Murray identified poverty, illness, loss,
teacher (or educator) is required to: lack of encouragement, and lack of help as those
factors that hinder attempts to reach a goal.
• Set a positive climate for teaching. Abraham Maslow (1908–1970) went a step
• Organize and proffer necessary learning further than Murray and defined a hierarchy of
resources. needs that the individual desires to have satis-
• Define the objectives and purposes of the fied (Fig. 14.2). All human motivation results
learner. from this hierarchy, and Maslow stated that
• Equalize the intellectual and emotional com- each level must be satisfied before the individ-
ponents of learning. ual can move to the next higher level. As the
• Empathize with, but not control, the learner. needs of each level are satisfied, the next higher
level in the emotional hierarchy asserts itself
The teacher’s tasks are clearly stated so that and dominates the functioning ability of the
the learner can achieve the defined objective. individual.
Learning is promoted or facilitated when: The hierarchy begins with basic physiologi-
cal requirements, such as the need for air, water,
• The learner participates and controls the learn- food, clothing, and warmth. Once these needs
ing process. are met, the individual then seeks shelter and
• The learner deals with personal, practical, security. Once shelter and security are obtained,
research, or social problems that are relevant
to her or him.
• Progress is assessed through self-evaluation.
Rogers noted that learning in itself is threaten-

ing since the learner is faced with new attitudes
and new material. Assimilation of new material is
simplified when the threat is minimized, usually
by linking the new material with past learning.
Fearfulness impedes and restricts learning;
removal of this fear (by building on what is
known and familiar) lessens the threat and speeds
the learning. Above all, learning that is self-
initiated is extensive and the most long-lasting.
Another noted humanist, Henry Murray
(1893–1988), theorized that human personality is
affected by inborn needs. He classified these Fig. 14.2 Maslow’s hierarchy of needs. (© The Asthma
needs as follows: Education Clinic Ltd)
there arises the need for love, affection, and a 14.4.3.1 Relevance of Humanistic
sense of belonging. The focus then switches to Theory to Asthma Education
the need for self-preservation and growth of In the humanistic approach, learning should be
self-esteem. After all these needs have been sat- self-motivated and self-directed [3]. This is mir-
isfied, the individual seeks self-actualization. rored in the field of education since the goal of
The ultimate goal is to achieve full integration education is to change behavior, and behavior
of the personality or “self-actualization.” change can only be wrought by the individual.
Maslow believed that all behavior is directed Application of this theory requires the asthma
toward the need level that is not being ade- educator to:
quately met. Thus, as each need is satisfied, the
next higher level in the emotional hierarchy • Set a positive climate for teaching and
asserts itself and dominates the functioning learning.
ability of the individual. As the lower needs are • Organize learning to satisfy the learner’s
met, the motivation to meet the next higher level needs.
emerges. He believed that it becomes progres- • Define the objectives of learning.
sively more difficult to meet the needs at higher • Allow the learner to set the speed and direc-
levels and that very few people actually reach tion of learning.
the level of self-actualization. • Link new learning to past experiences.
For the few that do achieve self-actualization, • Identify individual factors that hinder
it is a lifelong process. learning.
Viktor Frankl (1905–1997) [8] redefined
Maslow’s hierarchy. As he saw it, the ultimate
goal is not to achieve self-actualization but to find 14.4.4 Information Processing
meaning in one’s life. Man’s ultimate desire is to
have a life that is as meaningful as possible. That This theory attempts to explain how the brain
requires that man reach a state of self- works and how learning occurs. It is based on the
transcendence. Frankl states that self-premise that learning is the processing of
actualization is not possible by itself. It can only information.
be attained as a side effect of self-transcendence. Basic learning begins when sounds are
He believed that the more one strives solely for attached to objects by giving them names. In
self-actualization, the further it slips away. One time, these sounds are replaced by symbols of all
becomes more human when one forgets oneself kinds, including the basic alphabetical and
and thinks and cares for another. numerical symbols. For instance, a child is taught
Transcendence occurs in one of three ways— to associate the word “chair” with a particular
by experiencing something or someone, by cre- object. In due course when the child learns to
ating a work or doing something, and by one’s read, the sound of the word is associated with the
attitude toward unavoidable suffering. One can particular combination of symbols or letters that
choose one’s attitude toward suffering. Frankl spell “c-h-a-i-r.” The result is that the child can
suggested that suffering should be seen not as a conjure up a picture or knows what a chair looks
deprivation of happiness (happiness, after all, is like when he reads the word “chair” in a book.
not a right) but as ennobling rather than Another illustration would be the number 2,
demeaning and diminishing. The ultimate goal which the child may initially associate with two
is for man to go beyond himself and to forget particular objects. As the thinking grows more
himself in love and service to others. The para- abstract, the number 2 is seen as a quantity of
mount desire of every individual is to find anything that is more than 1 but less than 3.
meaning in one’s life and that can only be Learning is governed by the symbolic process.
attained by going beyond oneself—by achiev- Auditory function requires that sounds and com-
ing self-transcendence. bination of sounds be recognized as a form of
language. Visual function requires the ability to In his theory of information processing,
read printed symbols and interpret their meaning. Jerome Bruner (1915–2016) believed that any
This requires recognition of objects seen and subject could be taught to a child, at any stage of
messages heard or read. Comprehension of these the child’s development, if that subject was intro-
symbols, and the information they represent, duced in the appropriate manner. He felt strongly
occurs through the sensory channels. An that all children have a natural curiosity that spurs
increased mastery of the understanding and them on to learn and become competent at a vari-
manipulation of symbols in different areas—such ety of tasks. However, when a task is introduced
as language, art, music, mathematics, and sci- in a way that appears to be too difficult, the child
ence—allows for greater abstract thinking. becomes bored and does not learn. Therefore, it
Learning then becomes an interpretation of these is the teacher’s responsibility to present the work
symbols with their associated rules of usage. As at such a level as to challenge the child in his cur-
intellectual growth occurs, the level of symbol- rent developmental stage.
ism increases in complexity. Bruner assigned three stages to the cognitive
The classical approach to information pro- growth of a child:
cessing states that learning begins with input of
information (Fig. 14.3). Input is based on sen- • The enactive stage, where the child’s knowl-
sory receptors that see, hear, feel, taste, or smell, edge is psychomotor-derived, where the envi-
in effect, a sensory stimulus involving any (or ronment is understood through action, and
any combination) of the five senses. This exter- where action and knowledge are
nal stimulus is then interpreted, recognized when synonymous.
possible (by being related to a past experience), • The iconic stage, where decisions are sensory
analyzed, processed, and stored. Processing based and the child uses both visual and audi-
requires that the stimulus be accepted or dis- tory imagery.
missed. If dismissed, the information is forgot- • The symbolic stage, where information is
ten. If accepted, it is stored in some form in the stored and retrieved through the use of sym-
human memory. It can then be recalled and put bols and formulae. Understanding occurs
to use. through systems of symbols, particularly
The classical approach compared the func- language.
tioning of the brain to a modern-day computer
with a central processing unit (CPU) and a mem- Bruner believed that learning was an active
ory that can be recalled in any sequence. The process where through selection and transforma-
input can randomly or directly access specific tion of information, the learner can not only con-
memories without having to go through all the struct hypotheses but go beyond the basic
other memory cells to find the required information received. All new ideas and concepts
information. are based on past experiences and knowledge.
Fig. 14.3 Information processing theory: the Classical approach. (© The Asthma Education Clinic Ltd)
Therefore, teaching should take into account four upon. Knowledge is important, but it is the skills
important considerations: associated with solving problems that are critical
for development.
• The learner’s predisposition toward learning Development is thus a complex process that is
• The structure of the material, which should be engendered by cultural and social conditions.
presented in such a way that it is most easily Hence biological and cultural development do
grasped by the learner not occur in isolation, for they are interrelated.
• The most effective way of sequencing the Vygotsky categorized human functions as
material “lower” or “higher.” Lower mental functions are
• The nature and pacing of both rewards and unmediated, genetically inherited, and involun-
punishments tary. All higher functions have their origin in rela-
tionships between individuals. Higher mental
Bruner expanded his theories to include the functions are socially acquired, socially medi-
social and cultural aspects of learning. While he ated, and controlled voluntarily in accord with
believed that culture molded one’s thinking, it social customs.
was Lev Vygotsky (1896–1934) who saw the As a proponent of information processing the-
social environment as critical to the child’s cog- ory, Vygotsky advocated “directed learning”
nitive development, for it is the child’s world that which demands an understanding of what the
is the source of all concepts, attitudes, beliefs, child can do alone and what the child can do
skills, and ideas. under the guidance of a knowledgeable tutor. The
Vygotsky believed that all human functions difference between these two levels of function-
were social in origin. Social interaction is funda- ing is the zone of proximal development (ZPD).
mental to the emergence of thinking. Every func- The ZPD is influenced by experience, culture,
tion appears first at a social level and then at an and society. Teaching requires a recognition of
individual level, in the development of the child. where the child is in the ZPD and instructing the
Social environment is important to the child’s child at a slightly higher level to develop his
development for it can hinder or accelerate that potential through the use of multiple strategies,
development. assistance in finding solutions, and monitoring of
He identified language as a functional use of his progress. Adult guidance or peer collabora-
signs and as a tool used by society to organize tion will assist in the development of skills at a
thinking and one where the primary function of higher level than that attained by the child alone.
speech is communication. When a word is per- The effective tutor mediates between the environ-
ceived (seen, heard, read, or thought), it carries ment and the child, providing constant assess-
with it all the psychological events associated ment, instruction, and guidance as the child
with it in the individual’s consciousness. The progresses.
context of the word affects and determines its The most recent approach to information pro-
meaning. cessing theory is defined as connectionism [9].
Thus, he believed that cognitive development This is a multilayer system, as illustrated in
demands social interaction, since culture deter- Fig. 14.4. The brain is seen as a network of paral-
mines the social process that precedes psycho- lel processing units. These similar processing
logical growth. units allow interconnection in countless ways, so
Vygotsky asserted that all knowledge is social that tasks can be completed. Input, in sensory
before it can be made personal. Learning is the form, comes from the environment. As the input
day-to-day process of solving problems that are is received in the “input unit,” it activates an input
generated by conflict between the individual’s function. Multiple layers of processing units
inclinations and social dictates. Hence, children within the system, called hidden units, discern
learn to do what society permits and promotes certain features in the input and determine the
while learning to avoid that which is frowned correct input function to be activated.
14.5 Online Learning: Some Considerations 491
Fig. 14.4 Information processing theory – Connectionism. (© The Asthma Education Clinic Ltd)
One of the functions normally activated is The theory also requires that an assessment of
storage, either short term or long term. Long- the learner be made prior to beginning the teach-
term storage takes place in some form in the ing process. There is no purpose in teaching
memory so that when given the appropriate stim- someone the basics of asthma if the person
ulus, the information can be recalled. The appro- already has some knowledge about asthma. It
priate input function triggers an activation becomes more important to find out how much
function in that section of the processing unit the individual or learner knows before teaching
called the hidden units. The activation function commences. Hence an assessment is required
also mobilizes certain functions in the output before a teaching plan can be devised or the
unit, which in turn influences the start of an out- actual teaching can take place. Teaching then
put function, which determines the final response. must fit the needs of the person being taught. This
If the process is repeated often enough, the “path- theory also emphasizes the importance of a mul-
way” becomes established. That is, the more tisensory approach to facilitate learning.
often the input takes place, the more secure the
memory and the swifter the recall.
14.5 O
nline Learning: Some
14.4.4.1 Relevance of Information Considerations
Theory to Asthma Education
This theory is useful in that it dictates a step-by- Online learning was little more than a curiosity
step, logical approach through which the learner just 30 years ago; today, it stands poised to be an
progresses from the simple to the complex. It calls important addition to the educator’s toolkit. It is
for information to be structured in such a way that hence briefly worth considering.
it is easily understood and learned. Every step As with all the other theories of learning,
must logically follow the previous step for learn- online learning has its own underlying principles,
ing to be retained quickly and efficiently. For and these have evolved from the major learning
instance, a person with asthma must learn how to theories discussed earlier. Whereas previously
correctly use a peak flow meter before graphing learning was aided only through the use of so-
and interpreting peak flow readings. called hard-copy media (printed books, journals,
This theory further augments the belief that magazines, and research papers), today a good
repetition and reinforcement are required for Internet connection and the necessary computer
learning. In this, this theory is no different from equipment are all that is necessary to access a
that of the behaviorists. It also explains why it is world of digital information.
recommended that the use of the asthma inhaler Initially, computer-assisted learning (CAL)
be checked at every opportunity. Mistakes easily was crude, with static material being displayed to
creep in, and since technique is important, con- a student and quizzes being presented and scored
sistent and regular checking ensures that the by the computer. Live teaching was not a consid-
inhaler technique does not deteriorate. Repetition eration. Today, with massive advances in com-
and reinforcement are required for learning. puter technology and the application of artificial
intelligence to computer-based education, a num- • Content—which uses a so-called learning

ber of the traditional activities performed by the management system (LMS) and a content
teacher can be taken over by the computer. Yet at management system (CMS) and various forms
the same time, through videoconferencing (where of electronic media to deliver material
one instructor talks to many students), live teach- • Social considerations—which include the
ers have become more powerful than before— emotional component that is provided by face-
they can now have a “virtual” classroom that to-face tutoring
stretches around the world. • Self-paced learning—in which students study
CAL is a complex topic. This section will independently at their own speed, using spe-
briefly consider just one aspect: online collabora- cial purpose-designed software that tracks
tive learning, or OCL, which focuses on enhanc- their progress
ing communication between teachers and • A discussion board—providing room for dia-
learners. lectic questioning and interaction
OCL follows three basic, traditional • Evaluation—through analysis or assignments
principles: that permit assessment
• Collaboration—permitting group-generated
1 . Generation of ideas content and peer review through collaborative
2. Organization of ideas software (such as Wiki) that permits many
3. Convergence people to contribute to, and edit, a document
• Reflection—through the use of a blog or a
The generation of ideas comes from present- journal which allows the learner to document
ing a topic to students and allowing them to personal progress
“brainstorm.” Any and every idea, no matter how
obtuse, is discussed and validated. Divergent While OCL has become the new “norm,” it
thoughts and suggestions are accepted without has also exposed many significant problems. A
judgment. recent study by Friedman et al. [11] found that it
Once numerous ideas have been generated, a exacerbates existing racial, ethnic, and socioeco-
form of organization takes place. This involves nomic disparities. Using data from the US Census
discussion of the relative merits of each idea. Board’s 2020 Pulse Survey from August 19,
Argument occurs together with analysis and 2020, to October 26, 2020, they estimated that
comparison and finally categorization. 58% of US children participated in online learn-
Convergence occurs when a collective deci- ing. But they also discovered that one in ten of
sion is made and certain ideas are further these children had inadequate access to the
explored. The group then works together to pro- Internet and a computer. A further stratification
duce a joint piece of work. of the data by parental race and ethnicity revealed
It is in the implementation of those principles other disparities:
that OCL differs from traditional approaches. But
the concept is so new that various teaching mod- • On average, just 1.9% of the children of Asian
els have been created and are being tested, but no parents with graduate degrees had inadequate
one model has emerged a clear winner. Courses access to the Internet.
can be comprised of distance education, a modi- • On average, 35.5% of the children of Black
fied form of distance education, a teacher-led parents who had less than a high school edu-
fully online course, or a blended course. And, as cation had inadequate access to the Internet.
with all theories of teaching, there is no one solu-
tion that will fit all students. However, all these OCL offers a number of advantages, with flex-
courses will contain three or more of the basic ibility being among its prime benefits. This has
elements in OCL. been particularly apparent with the arrival of
The basic elements of OCL include [10]: COVID-19. The pandemic has also highlighted
the stark socioeconomic differences between stu- a quantifiable and proven explanation of how an
dents. Education is a key social determinant of individual’s personality develops and changes
health. But, in a technologically driven approach with time.
to education, students who do not have the neces- In the area of personality development, the
sary access to computers are at a tremendous dis- foremost theorist is Erik Erikson (1902–1994).
advantage. It does not matter how excellent the Unlike Maslow and Murray who defined person-
OCL program if the student cannot access it ality in terms of need, Erikson believed in self-
either because of lack of finances or lack of actualization, but one achieved through the
access to the Internet. process of crisis resolution and resolution of
Videoconferencing facilities, such as those basic psychosocial problems. He believed that a
provided by Skype, Zoom, and others, make it person could only grow when faced with a chal-
easy for an asthma educator to reach any size of lenge that demanded interaction and that it was
audience. But all too often that audience may mastery of these successive challenges that
have excluded people without access to the resulted in a healthy personality. He enumerated
Internet. It is particularly important to reach the the following sequence of crises as age-related
under-privileged with asthma. While a phone call [3, 4].
would be helpful, a face-to-face virtual encounter
has more impact. To give just one example,
proper inhaler technique can be both demon- 14.6.1 Infancy: Trust Versus Mistrust
strated and checked.
One suggestion for teaching such people The initial exposure to love and attention often
would be to use public library facilities. The determines the future response. Fundamental
library could make available a small room feelings of trust are based on the initial exposure.
equipped with an Internet terminal. At a prear- Trust is the outcome of reliance on another
ranged time, the asthma educator and the person human being and is a confident expectation that
with asthma could hold a face-to-face meeting in what is done is for one’s benefit. Order and pre-
privacy, thereby making a home Internet connec- dictability are essential to laying the foundation
tion unnecessary. for trust, which in later years will provide psy-
In this time of COVID-19, it is imperative chological strength, hope, and confidence.
that the asthma educator find ways to continue Mistrust creates suspicion, doubt in one’s self,
interacting with those who have asthma. Even a and lack of confidence.
brief encounter can have a positive impact.
COVID-19 has widened the gap between the dif-
ferent echelons of society. Education can help 14.6.2 Early Childhood: Autonomy
reduce it. Versus Shame and Doubt
Based on the initial sense of trust or mistrust, the

14.6 Personality Development child may develop a sense of self-control without
a loss of self-esteem. The child will test the par-
Learning theories try to explain how people learn, ents and discover those things that can and can-
whatever their age. Age brings with it certain not be controlled. The child begins to govern
physical and personality changes, and these have himself. Excessive parental control will lead to
a profound effect on learning. It is to the asthma self-doubt and shame about body, bodily func-
educator’s advantage to understand the changes tions, and needs. Too little control results in wil-
that occur in personality between birth and old fulness, lack of self-control, a corresponding lack
age. Again, this is a field that is strictly theoreti- of trust, and a deepening awareness that the child
cal since there cannot be, in the nature of things, cannot rely on the parent.
14.6.3 Middle Childhood: Initiative 14.6.6 Young Adulthood: Intimacy

Versus Guilt Versus Isolation
Between the ages of 3 and 5, children explore on Identity is further established, and the focus now
their own and are led by their curiosity. Their sense moves away from the self and begins to include
of conscience begins to develop. The beginning of others. Resolution of the crisis between intimacy
personal responsibility emerges. Disobedience to and isolation can result in confidence and the
parental restrictions induces guilt with the realiza- ability to give and receive love or, on the other
tion of the difference between right and wrong. In hand, to psychological isolation. The goal is to
these years, encouragement to explore the physical attain intimacy with another individual. Failure
and social environment fosters initiative. Excessive results in an emotionally inharmonious personal-
restriction results in a constricted personality ity who cannot give or receive love.
prone to guilt. Lack of restriction may result in a
person lacking in conscience.
14.6.7 Adulthood: Generativity
Versus Stagnation
14.6.4 Elementary School Age:
Accomplishment Versus In this period, from 25 to 65 years, maturity is
Inferiority established. Since maturity is the full develop-
ment of personality, it ordinarily requires that
These are the years when the child seeks to one become mature through caring for another.
accomplish things and do them well. Preventing This is typically accomplished through child-
these feelings of accomplishment results in feel- bearing and child-rearing. Guiding the develop-
ings of inferiority. The person will feel inade- ment of the next generation is the major focus.
quate and unable to cope. Successful experiences Creativity and the desire to be a productive
promote self-confidence and self-esteem. member of society become exceedingly impor-
tant. Intergenerational activities are a priority. A
positive resolution of these crisis results in a
14.6.5 Adolescence: Identity Versus socially conscious personality, while the oppo-
Confusion site results in an isolated, bored, apathetic, and
stale individual, unable to maintain a personal
These are very difficult years as bodies change, relationship.
hormone levels rise, sexual forces dominate and
desires surge. There is conflict between physical
and mental forces as the adolescent seeks to 14.6.8 Old Age: Integrity Versus
affirm personal identity as distinct from the fam- Despair
ily and one in keeping with that of peers. Social
concerns dominate. There are also apprehensions This is the final crisis, the period of acceptance
about individual identity and the adolescent’s when one acknowledges what has (and has not)
role in the future: concerns about a future career, been achieved and learns to either accept or
health and sexuality, personal identity, and social repudiate it. Satisfaction with one’s self results
acceptability. Failure to affirm the individual’s in dignity and serenity that life has been well
identity prolongs this period of adolescence and lived and that much has been accomplished.
limits the ability to function in an adult role. It Disappointment can result in despair with the
also results in difficulty coping, feelings of inse- feeling that life has been wasted and lived with-
curity, and a lack of self-confidence. Healthy out aim or purpose [12].
resolution of these crisis results in a well- Erickson’s theory of personality development
adjusted, capable, confident adult. is just a theory and one without objective and
supportive data. It was based on his real-life Table 14.2 A summarized comparison of the theories of
learning
observations, on people around him as they grew,
developed, and matured. His sequence of crises Theories of learning
does make logical sense and can serve as a guide Theory Elements
Behavioral Stimulus leads to a response
to the educator. Most educators will instinctively Reinforced behavior is repeated
relate to the different age-related crises and even Negative reinforcement suppresses
identify with some of them. This theory covers behavior
all the possibilities for personality traits in the Recurrent behavior is reinforced
behavior
human compendium. Immediate and consistent reinforcement
strengthens the behavior
Behavior is influenced by rewards and
14.6.9 Application of Theories punishments
Gestalt Behavior is more than a conditioned
to Asthma Education
response
Sensory awareness modifies perception
As stated at the beginning of this chapter, each The individual’s experiences affect
learning theory has its strengths and its weak- perception
Learning is an active continual process
nesses. There is no single approach that answers
Learning is affected by previous
all the educator’s questions. Rather, each theory experience, ability, and developmental
provides a window or a perspective on under- phase
standing the cognitive behavior of the learner, Humanism Learners should be involved in the
and each offers suggestions as to how learning process of education
Conscious experience is important
can be facilitated. Learning is self-actualization
The successful educator uses a combination of Affective learning is equally important
these four theories to help understand how a per- as cognitive learning
son learns and as a guide to how they may behave. Education should occur for its own sake
Information Learning is information processing
The salient points of the four theories are listed processing Learning begins with sensory perception
in Table 14.2. From these, the important basic Repetition promotes learning
principles that govern learning can be derived: Requires assessment of the learner
Learning requires registering, retaining,
and recalling information
• Reinforcement and repetition are required for Learning with guidance results in
learning. greater range of skills
• The learner interprets all learning in the light
of previous experiences; hence, perception of
new information is colored by past cial concern. They emphasize the importance of
experiences. understanding how children think, of using con-
• Age is a factor to be considered in the learning crete examples in the teaching of young children,
process, since it is directly related to both and of the need for sequencing of instruction.
intellectual development and the degree of Since the thought processes of children are
experience the learner possesses. developmentally determined, teaching them con-
• The learner cannot be taught unless willing to cepts through simple reinforcement can often
learn. prove inadequate. The child cannot assimilate or
• Motivation plays a large part in the learning grasp these concepts if mental development has
process. not yet reached the proper stage. Thus the teacher
• Basic needs (including freedom from fear) should not be a conduit for information but a
need to be met before learning can take place. guide to the child’s discovery of his own world.
The theories provide insight into ways of
For the educator, the implications of Piaget, introducing new material (some novelty is help-
Bruner, and Vygotsky’s theories [1, 4] are of spe- ful, too little makes it boring, and too much con-
fuses) and how to set the pace for learning. They age on learning, the different methods of learn-
emphasize the importance of the social aspect of ing, and the planning that must take place prior
learning and acknowledge cultural connections to teaching. The connection between age and
and the need to analyze errors in learning in order the type of learning that occurs will be discussed
to understand the thinking sequence utilized. in the next section.
Above all, the theories emphasize that children
are not a younger version of adults.
Individuals are free to choose their attitudes, 14.7 Age-Related Learning
beliefs, and interpretations of events. Their
response to a chronic illness such as asthma is a The various theories of learning all share the
choice they make, and no matter how self- belief that people are purposeful beings with
defeating their chosen behavior, the asthma edu- the ability to organize information. They all
cator should not pass judgment on them. The agree that every person has a personal reason
asthma educator must make individuals with for learning. Some people may learn because
asthma aware of the consequences of their learning itself provides satisfaction or because
choices yet allow each one to make a personal a lack of learning is seen as threatening to
choice. They have a right to be aware of all the self-worth; others may learn to advance their
options available to them and to make their own careers; still others may learn for any of a
decisions. The goal of the educator is to help number of other reasons. For those with a
them make informed decisions. chronic illness, the reason most often quoted
For the asthma educator, there is one further is that knowing more about the disease helps
principle to keep in mind. The asthma educator them adjust and live with it. Knowing imparts
needs to understand that the responsibility for a feeling of self-confidence and of being able
learning lies with the individual. Learning has to cope despite the fact that knowledge alone
many components to it and so does teaching. does not help them cope. The application of
But teaching for learning requires an under- knowledge will help them manage the disease,
standing of those segments (see Fig. 14.5)—that but they have to be taught how to apply the
is, of the theories of learning, the influence of knowledge.
14.7.1 Learning Styles
Each person learns differently, and each has a

unique learning style. “Style” refers to the way
in which each person processes information.
This is unrelated to a person’s abilities but refers
rather to the method used for problem-solving
and thinking. In effect, it describes a tendency
of behavior. While people learn in myriad ways,
most learn by subconsciously selecting a set of
approaches or techniques that suit their person-
alities and with which they feel comfortable.
Each person’s learning style depends on the way
their mind functions and how it relates to the
world—to heredity, experience, and the
demands of the current environment. Thus,
Fig. 14.5 The components of teaching. (© The Asthma learning styles change with age and with the
Education Clinic Ltd) increase in experience.
Adults and children learn in very different • Interpersonal—requiring external motivation

ways. Whether teaching children or adults, to learn. These children learn best when sur-
understanding their developmental age and rounded by others.
needs is fundamental to the entire practice of • Intrapersonal—manifested in self-motivated
teaching. children who prefer to learn in solitude.
• Natural—where learning occurs through
observation.
14.7.2 Children
Gardner theorized that each child has all these
Piaget’s contributions to behavioral learning intelligences, but to differing degrees, and that
theory were discussed earlier in this chapter. children instinctively discover which intelli-
He defined four levels—sensorimotor, preop- gences are best suited to them (or, to express it
erational, concrete operational, and formal differently, what “works” and what “does not
operational—each of which constitutes a work” for them) as individuals.
phase in the child’s mental and intellectual The intelligences do not operate indepen-
development. dently but are used together, in a complementary
Children initially try to master their envi- manner, to aid both learning and problem-
ronment through physical manipulation and solving. And as children grow and learn, they
imitation. This in turn is succeeded by initia- refine those personal skills that enable learning to
tion of activity and the beginnings of a con- occur. In effect, they build on and develop their
science. The school-aged child develops a strengths.
sense of self-worth and works to develop skills Children tend to accumulate knowledge in
in different areas. the belief that it will be applicable later in life.
Howard Gardner defined the theory of mul- They tend to be subject-centered and accepting
tiple intelligences [13] to explain how children of whatever happens to them. They do not
learn. According to Gardner, every child is born choose their experiences. They are more com-
with certain existing tendencies or natural abili- pulsive about learning, are driven to learn, and
ties. These are innate and recognizable in their are very dependent on adults to give them infor-
preferences. Gardner listed these intelligences mation and knowledge in a variety of ways.
as being: They are nonjudgmental about the information
they receive.
• Verbal or linguistic—shown in a love of Because of their lack of experience, they can-
words, reading, writing, and storytelling. not compare what they have learned with past
• Logical or computational—indicated by a experiences.
love of logical and deductive reasoning,
together with an ability to recognize
patterns. 14.7.3 Adolescents
• Spatial intelligence—revealed in the ability to
visualize things mentally. This propensity is Adolescents try to integrate their identity, per-
seen even in blind children. They learn best forming many roles (child, sibling, student, ath-
through pictures and mental images. lete, worker, would-be adult) with a strong
• Kinesthetic—as in those who use touch and emphasis on the social aspect of personality. Role
movement. Mental faculties are used to coor- models are very important. Thinking is increas-
dinate body movement, and children who are ingly rational, logical, and abstract. Social con-
kinesthetic learners use movement to facilitate cerns develop and idealism increases. In all
learning. likelihood, adolescents will challenge and ques-
• Musical—shown in the love of rhythm and tion information. During adolescence, cultural
melody. identity can be difficult to establish, especially
for minorities. Erikson’s theory of the adoles- Strategies for dealing with adult learners
cent’s “identity versus confusion crisis” fits well
in here.
set a cooperative climate
mutual planning
14.7.4 Adults diagnose needs

define objectives based on needs
Malcolm Knowles (1913–1997) is the theorist arrange sequential activities
most often cited for this age group, for he defined carefully select methods, materials and
the art and science of how adults learn [14]. He
resources
listed four assumptions that distinguish adults
from children. These include self-concept, expe- evaluate the learning experience to diagnose
rience, readiness to learn, and orientation to further needs
learning.
Adults are self-directed with a large store of
experience that they use as a resource [15–21].
Their learning is problem-centered with a strong
motivation to apply learned material to their Fig. 14.6 Teaching strategies for adults. (© The Asthma
immediate situation. They are motivated to learn
when they change or assume new roles. They pre-
fer immediacy of application to postponement by body builders; and that the dosage in micro-
and are both influenced and motivated to learn by grams was minuscule and did not enter the rest of
social roles. See Fig. 14.6. the body, she was prepared to try the medication
Adults are selective learners, evaluating every- for a period of time and to discuss her concerns
thing that is given to them in relation to their past with her healthcare provider on her next visit.
experience. Their identity is the result of the This person had made an incorrect assumption
unique situations they have encountered, and all based on her current knowledge and had been too
adult learning takes place in the context of per- upset to discuss the matter with the prescribing
sonal experience. This is well illustrated by the healthcare provider.
case of a 35-year-old female who phoned an Knowles devised a strategy for dealing with
asthma educator. She was angry and upset that her adults that was both humanistic and democratic.
healthcare provider had prescribed “asthma medi- He proposed guided interaction. He suggested
cations” for her while she was recovering from that when dealing with adults, educators should
pneumonia following bronchitis, and she was first and foremost set a cooperative climate for
absolutely certain that she did not have asthma. learning. This should be followed by mutual
She was not going to take “asthma medications.” planning, diagnosis of the learner’s needs and
This person was fearful of taking corticosteroids interests, definition of the objectives based on
since she had heard that they had serious potential those needs and interests, and arrangement of
long-term effects. She had assumed that the medi- sequential activities to achieve the defined objec-
cations prescribed were to be used only for tives, with all of these being combined with a
asthma. Once it was explained to her that the con- careful selection of methods, materials, and
troller medications were used to reduce the resources. In turn, this should be followed by
inflammation in the airways and that it was diffi- evaluation of the quality of the learning experi-
cult to be sure early on whether her “bronchitis” ence in order to diagnose needs for further learn-
was an infection only or an early sign of asthma; ing. Learning then must be self-directed and the
that the corticosteroids were not the steroids used teacher becomes a facilitator of learning.
14.7.5 Older Adults a major obstacle when dealing with a chronic ill-
ness that affects every life phase and experience.
There are many myths about older adults and
learning. The notable psychological feature of
aging is the impairment in short-term memory and 14.7.6 Implication of Learning Styles
the increased time required for a response. There is
no loss or decrement in vocabulary, general infor- Learning may occur through what is observed,
mation, or habitual activities. Experimental stud- heard, or done. Draper defined learning as the
ies show that, when not restricted by time, the “process whereby, through one’s senses, an indi-
older adult can perform as well as a young adult in vidual comes to understand, interpret, interact
learning and memorizing material. As adults, they with and to adapt to one’s environment” [23]. The
are selective and build on past experiences. Their more senses involved in the process, the greater
behavior patterns tend to be more rigid and less the degree of learning that takes place. New mate-
flexible. The older adult is more cautious. Health rial is often assimilated by looking for similarities
concerns have a major impact on learning as does, with previous experiences. None of these pro-
to a lesser extent, deterioration in visual acuity, cesses occur in isolation, nor are they distinct
hearing, and reaction time. from one another. Learning takes place through a
P. Cross [22] extended the adult learning model combination of these processes, and the dimen-
by including two variables, that of personal char- sion of each varies according to the individual.
acteristics and situational characteristics. Individuals rarely belong to a single group in
Personal variables involve developmental their approach to learning. Previously, despite
stages, life phases, and aging. Every individual there being no evidence for this, learners were
adult goes through distinct stages such as mar- categorized as auditory, visual, kinesthetic, or
riage/commitment, job changes, and retirement. read-write. Doing so put learners into specific
Aging brings some loss of sensory-motor abili- limiting categories that were potentially harmful
ties (vision, hearing, etc.) but increases and reduced motivation to learn [24]. Today edu-
intelligence-related abilities such as vocabulary, cators realize that the various learning styles are
reasoning, and decision-making skills. a continuum through which an individual moves.
Situational characteristics relate to the kind of In time, the person will choose those styles which
learning that occurs, whether full-time or part- work best and with which the individual is most
time, voluntary or compulsory. Simple examples comfortable.
of the different motivations for adult learning People have their own preferences [16–21]
would be the type of learning done by a parent and strengths in the way they process informa-
who only wants to know how to prevent asthma tion. David Kolb [25] classified these preferences
exacerbations in her child or by an adult athlete into four basic methods, a continuum that
with exercise-induced asthma whose only con- includes the following:
cern is to avoid interruptions in training or by the
asthma educator who needs more specialized • Concrete experience (CE)
learning. The motivation for each is different, and • Reflective observation (RO)
the amount and level of learning that occurs in • Abstract conceptualization (AC)
these three instances will also differ according to • Active experimentation (AE)
needs and purposes.
Thus, the educator must not only capitalize on Some people prefer to learn by feeling and per-
the experience of the learners but also consider sonal involvement. This is a tactile approach that is
needs and provide as much choice as possible in tangible and explicit. Others prefer to observe and
the organization of learning experiences while then think about concepts. They examine, inspect,
helping them progress through the transitions of scrutinize, and then infer conclusions. Still others
the current life phase. Individuals with asthma face prefer to analyze and organize concepts intellectu-
ally and deal with them on an abstract plane. They However, individuals rarely learn in one particu-
then generate principles and applications from lar way. Recognizing this, Kolb defined individu-
these concepts. They prefer abstract thinking als who prefer concrete experience and active
rather than doing, but they also enjoy applying experimentation as accommodators. They prefer
their thinking to solving problems. They create facts to theory and want to make things happen.
theories to explain observations. The last group They are activists. Those who combine concrete
favors thinking and then doing or experimenting to experience with reflective observation are diverg-
confirm or deny the concepts. ers. They want to know the “why” and prefer
Kolb theorized that all learning can be defined information that is detailed and systematic in pre-
either in the way it is perceived or the way it is sentation. They are reflective, imaginative, and
processed. If the four groups are envisioned as innovative. When active experimentation is com-
four quadrants of a circle, then individuals will bined with abstract conceptualization, the learner
find themselves tending toward a combination of is called a converger. Convergers are pragmatic
any two of the four quadrants or dimensions. See and want interactive instruction and practical
Fig. 14.7. The CE/AC and AE/RO methods are applications. Assimilators, who are theorists,
opposites in regard to learning styles. combine reflective observation with abstract con-
Kolb further defined four types of learners— ceptualization and prefer facts and an organized
divergers, assimilators, convergers, and accom- delivery of information. Briefly, accommodators
modators—depending on which position they and divergers constitute the processing contin-
occupied in the two dimensions of CE/AC and uum, while the convergers and assimilators
AE/RO. encompass the perceptual continuum.
According to Kolb, persons who prefer con- The disadvantage of Kolb’s theory is that it
crete experience tend to learn from feeling and leaves no room for the goals of the learner; its
personal involvement. Reflective observers are, as major advantage, however, is that it moves the
the name suggests, individuals who learn through focus from the teacher to the learner. More than
watching and listening. Individuals who learn by that, it emphasizes that the internal components
thinking are abstract conceptualizers and those are as important as the external factors that influ-
who learn by doing are active experimenters. ence learning.
Fig. 14.7 Kolb’s Styles

of Learning. (© The
Asthma Education
Clinic Ltd)
Theorists are constantly trying to understand

how people learn. Two of them—Felder and
Silverman—devised a model that encompasses
eight learning styles that give the learner consid-
erable leeway. Individuals may tend to favor a
single style but may use different styles at differ-
ent points in the learning process. Because of its
inherent flexibility, the model suggests ways in
which people learn. It is considered particularly
applicable to e-learning and can hence be related
to the information processing theory with its four
stages—perception, input, processing, and finally
understanding (output)—that encompass the
eight styles. See Fig. 14.8. Each learner instinc-
tively chooses the style that he or she is most
comfortable with.
Initially, in the perception stage, learners
may have a preference for a sensing approach
rather than an intuitive one. The “sensing”
learner is realistic and sensible and prefers
standard approaches, concrete facts, proce-
dures, and real- world problems, while the
“intuitive” learner favors abstract, conceptual
thinking, and theories. Intuitive learners are
innovative and creative, seeking new ways to
solve problems.
The input stage defines how the learner pre-
fers to receive data. This can be visual or verbal.
Visual learners prefer pictures, diagrams, flow-
charts, and similar aids, while the verbal group
prefers the written or spoken word.
Processing of received data is a more complex
process and occurs either actively or reflectively.
Active learners prefer application, to try out things
and work in groups; reflective learners prefer Fig. 14.8 The Felder-Silverman model of Learning
thinking about the data, and their preference is to Styles in relation to Information Processing. (© The
work alone or with one other individual. Asthma Education Clinic Ltd)
Understanding comes after processing the
incoming data, storing the processed results in
memory, and linking it to already-known facts. It Global learners see the “big picture”—they take a
is at this point that the previously raw data holistic approach, make giant leaps in their think-
becomes usable information that can be called ing, and hence are able to solve complex prob-
upon in the future to help with decisions and lems. While sequential learners are interested in
problem-solving. detail, the global learner values a broad range of
Learners can also be “sequential” or “global.” knowledge and an overview of the subject.
Sequential learners progress through small incre- Learning styles are not static. They change
mental, logical steps in a decidedly linear fashion. according to the learner and the way in which
information is presented. But more than that, ing. The multisensory approach followed by ver-
they are affected by gender (men are less likely bal interpretation ensures that the child
to be divergers), socioeconomic status, culture, understands what is being taught.
and level of education. Learning styles are Adults learn in a symbolic, more abstract way.
important for the educator, who must understand Therefore, for adults, all learning should be con-
that the learner’s experience cannot be ignored nected to their past experience [17–21, 26]. Adults
and, furthermore, that teaching must take into have a large base of experience to draw upon and
account the style of the learner. Hence a multi- generally know what they want in terms of educa-
sensory approach is a prerequisite to learning. tion and learning. Techniques such as discussion
No matter what style is used in learning, it and problem-solving are effective tools to help
involves two distinct processes, the experiential make that connection. Adults also learn from the
and the symbolic. In the experiential process, shared experiences of others; hence, group dis-
each action is followed by an observation of its cussions are an effective adult educational tech-
effect so that: nique, especially if the adults in the group are
comfortable working with one another.
• Understanding moves from the general to the
particular.
• General principles are deduced. 14.7.7 Types of Learning
• The new or newly learned material is applied
through action to new circumstances. The learning process is time-consuming, and
there are two types of learning—short term and
The symbolic process is a much more long term. Short-term learning occurs when the
abstract method. It requires that information be learner is presented with a large number of facts
received by the learner. This is followed by the that have no obvious relevance or connection to
following: his or her environment or lifestyle. The learner
will memorize the information and will be able to
• Assimilation and organization in order to find retrieve it for a brief span of time. This type of
the principles underlying the information accommodation during the process of assimila-
• Relation of the general principles to specific tion usually occurs for a specific purpose, such as
circumstances the immediate need to memorize facts for an
• Use of the principles to perform an action examination. But retrieval becomes increasingly
difficult with the passage of time. (Since the
Children tend to learn in the experiential man- information is perceived as being for a temporary
ner, more so than adults. The disadvantage of this purpose, once the purpose is served, no effort is
process lies in the third step, where particular made to assimilate and retain it.) The capacity for
experiences are needed to formulate a general short-term memory is limited. Short-term mem-
principle. This is time-consuming and requires a ory is conscious memory.
facility with language in order to formulate the Long-term learning takes time and effort. It
principle. Hence, when teaching children, experi- requires rehearsal, repetition, and organization
ential learning should be enhanced by the use of and only then will the information be transferred
the symbolic process (the use of spoken and, to long-term memory. The storage capacity of
where possible, written language). This approach long-term memory is enormous—it cannot be
is consistent with the stages of human growth and filled in a lifetime, but the ability to retrieve it
development of cognitive abilities, and it empha- may become increasingly difficult over time [3],
sizes the importance of experience in the learning though strategies can be devised to aid retrieval.
process. Models, charts, videos, and interactive Long-term learning is a much slower process that
computer lessons are all effective aids to learn- requires all three steps of interpretation, assimila-
tion, and manipulation. It is during manipulation

that learning is truly individualized, and it is this Proventil p.r.n. On further questioning, you
individualization that is the desired result of find that she has not used her inhaler in the
learning. last 8 months. What will you say to reas-
sure her mother?
If Jenny is exercising without difficulty,
14.8 Barriers to Learning has no symptoms, and does not need the
inhaler, she likely does not have current
Barriers to learning exist for every individual. asthma and does not require any treatment.
Sometimes they are present before the educator If her mother is still worried, reassure her
meets the person, and at other times, it is the that state teams usually have a physician in
educator’s approach that raises barriers for attendance so if Jenny has any problems,
some individuals. The former will be discussed she can see the physician in charge. She
in this section, while the latter will be addressed should be reminded to tell the team physi-
in Chap. 15 (Ways Teaching Can Cause cian about every medication—prescribed
Problems). by a physician, over the counter, herbal,
Barriers presented by the person with asthma “natural,” or health food “supplement”—
may be behavioral, cognitive, biological, and that she takes.
even environmental [27–29]. Their attitude and
behavior is influenced by many factors. Consider
a few of these: Negative influences that produce environ-
mental stress include low illumination, vibra-
tion, noise, odors, and glare. Ringing phones are
14.8.1 Environment a distraction. Colors also have an impact, and
the colors chosen for the walls should be sooth-
The learning and teaching environment—both ing, with decor that is understated and not eye-
physical and psychological—must be conducive catching or distracting. The teaching area should
to learning. In terms of physical factors, this means be quiet. External noises should not invade the
that the teaching area (its temperature, lighting, quiet of the room. Above all, plants and other
ventilation, acoustics, decor, and other facilities) possible triggers of asthma (scented markers, air
should be geared to the comfort of the learner. fresheners, external odors, etc.) should not be
present.
Privacy is extremely important. Education
Case Study cannot take place where there are people passing
Jenny’s mother has brought her in for help. through or telephones ringing. Nor do individuals
Jenny is an avid swimmer, doing on aver- with asthma want to talk about their concerns
age 30 laps a day in the pool. She also runs where they can be overheard. Hence privacy
between 5 and 10 miles (8–10 km) a day. should be ensured.
She has been chosen as a member of the The teaching environment must be such that it
state team and will have to live away from reduces or eliminates anything that may distract
home to train with the team. Her mother is the learner. For instance, the parent of a child with
worried. After Jenny had the flu last asthma may also have to cope with another child
January, she went on a 5 mile (8 km) run on demanding attention. If this occurs during the
a very cold day. Then she started wheezing. teaching session, the parent cannot focus on the
She was taken to the hospital where she information being provided or the skills being
was diagnosed with asthma and prescribed taught. Thus, some provision for looking after
children of parents must be made so that the
teaching is not disrupted. Alternately, parents 14.8.3 Individual Factors

could be requested to come alone, without their
children. There are many other barriers [31] such as the
Also important for learning is the location of following:
the teaching environment. Some people associate
hospitals with pain, health crises, and stress. • Level of literacy [32–35]
Others associate the hospital as a place where • Ethnicity [36]
they get relief from severe symptoms. So, asking • Socioeconomic status [37]
some individuals to come to a hospital for a • Language difficulties (particularly if English
teaching session can be counterproductive. is a second language)
Hence, where possible, a variety of alternate sites • Physical disabilities (visual and auditory
should be available and suggested for teaching difficulties)
purposes, including sites away from a hospital or • Lack of motivation
healthcare center. • Dementia and memory impairment
• Difficulty of content
• Lack of time to digest the teaching material
14.8.2 Physical Factors • Lack of time to practice behavioral changes
and develop skills
All too often, educators tend to ignore the physi- • Information overload (too much information
cal state of the learner. Teaching should prefera- being presented in one session)
bly not be scheduled for the end of the day, for • Stress from the disease
that is the time when people are fatigued and find • The individual’s or caregiver’s inability to cope
it difficult to concentrate. A person who comes
for an education session after an exhausting day The ability to read, repeat, and understand
at work may not be in a mental or physical state instructions is absolutely essential if a prescribed
to learn. medical regimen is to be properly followed. It is
Individuals have different physical needs that important to note that people do not read at their
affect their learning. Some learn best at night, educational level [26, 32, 33]. Further, intelli-
others in the morning. Some are able to work for gence is not correlated with educational level [3].
long periods; others need frequent rest breaks. One of the indicators of educational literacy is
Attention spans will vary from person to person, the level of vocabulary.
from age group to age group, and also from time Individuals who are not literate will take
to time for the individual, depending on a number words literally and be unable to deduce or make
of factors including the level of stress at that inferences from written information. For exam-
moment. ple, they may not know how to correlate
Hunger, fatigue, pain, sickness, and level of decreases in peak flow readings with an asthma
wellness [30] are also physical barriers to educa- action plan. They may be unable to comprehend
tion. If the person is ill or feels unwell, teaching written instructions, and the educator can be
should be postponed. Anyone suffering from an deceived into believing that they can follow the
allergic reaction will have a diminished ability to prescribed regimen.
learn. Some medications, such as first-generation It is a startling fact that a large number of
antihistamines, affect mental alertness. adults are functionally illiterate. In the USA
Sometimes it is worthwhile to determine if the alone, it is estimated that at least 1 in 5 adults (43
individual is on any other, non-asthma medica- million Americans) are unable to comprehend the
tion or taking over-the-counter (OTC) medica- written word or to interpret and follow written
tions. All these physical barriers reduce their instructions [38]. Reading and verbal skills in the
ability to learn. USA are declining. The percentage of illiterate
adults has risen from 18% in 2012–2014 to 19% opment but that different societies arrive at dif-
in 2017, while those at the other end of the scale ferent solutions to similar problems. Vygotsky
with the highest levels in literacy have dropped emphasized the role that each society or culture
from 50% to 48% [39]. plays in the development of the individual. Thus
Some individuals can speak, but not read, ethnicity and culture may often provide a behav-
English (but can speak, read, and write in their ioral response that is not in keeping with the cur-
mother tongue). It is hence important to discover rent milieu.
if the person is an immigrant, refugee, or visitor Illness is treated in different ways in different
who is in this situation. Literacy becomes crucial cultures. Many cultures prefer the silent, “stiff-
when dealing with mothers who are generally upper- lip” approach where the person is not
assigned the role of caregiver to the child with encouraged to discuss symptoms or draw atten-
asthma. Mothers with intellectual limitations tion to illness. This can be at odds with what is
[35] have difficulty with basic skills such as orga- required of a person with asthma who must, of
nization and decision-making, and this may result necessity, be introspective, keep watch for indi-
in lack of care, neglect, and noncompliance with vidual reactions, and then take measures to avoid
the prescribed regimen. These mothers tend not triggers. In Europe, the Middle East, and Asia
to report medical problems, to miss appoint- (particularly China) where the emotional
ments, to fail to correctly answer questions con- response to environmental tobacco smoke is min-
cerning their children, and to be unable to repeat imal when compared to North America, asking a
instructions from earlier visits. They are unable person not to smoke in your presence would be
to follow written instructions. They do not pro- considered insulting. Many cultures stress avoid-
vide adequate care, and the challenge of coping ance of introspection, so if the person is not will-
with a complex regimen, such as the one required ing to practice self-observation, much effort will
for asthma, is often beyond their abilities. be required by the asthma educator if asthma
Anyone who is below a literary level of Grade symptoms are not acknowledged.
5 will have difficulty keeping diaries. For these Socioeconomic factors play a major role in
persons, teaching methods must be heavily biased health. Exposure to allergens such as cock-
toward demonstrations, audiotapes, and video- roaches, to irritants such as tobacco smoke, to
tapes. Those between Grade 5 and 9 can use crowded inner-city housing, to alcohol, or to a
materials with low reading levels and pamphlets less than hygienic environment and lack of con-
[26]. tinuous medical care are some of the major draw-
Ethnicity, which includes race, culture, lan- backs to the well-being of the person with asthma.
guage, and diet, has a direct effect on the person’s Lack of financial resources is an impediment to
ability to learn. If there is a conflict between what health and compliance.
is suggested and what they know or do based on Individuals with asthma may not be motivated
cultural values, then the latter will prevail, and to learn because they are in denial—denial that
what has been taught will be ignored. (See Chap. they are vulnerable, denial that the problem is
11.) Ethnic backgrounds influence responses. For serious. There may also be a lack of positive
instance, in a culture where men project a strong, influences [40]. All these are additional barriers
silent image, weakness will not be admitted, and to learning.
the thought of seeking help will clash with their One of the most common misconceptions is
image of self-sufficiency. In some other cultures, that as people age, they lose the ability to learn.
men may be averse to taking instructions from In reality, they do not. Older people can learn as
women and vice versa. In that case, gender can well as young people if given sufficient amount
and will be a barrier. of time. However, older people many not be able
Erickson stated that every society develops to see well. Loss of visual acuity is age-related
institutions to accommodate personality devel- and can be compensated for by brighter lighting.
The teaching methods and materials used can Overriding concerns for the social and environ-
also constitute a barrier. Information overload is the mental changes required for the control of asthma
most common form for it leaves the person over- may make the moment inappropriate for teach-
whelmed with details and unable to see the connec- ing. Teaching cannot take place till fears are alle-
tion between the information and their personal viated and the individual is ready to learn.
needs. If the material is difficult to comprehend; Misinformation from family and friends can
uses medical terminology or jargon, acronyms, and create a barrier to learning. There may also be a
unfamiliar terms; or raises expectations without lack of belief in the diagnosis. If no other family
offering the chance to practice required behaviors member has asthma, a person may believe that the
and skills, then the teaching process has itself diagnosis was wrong. Or they and their family
becomes a barrier. For further information, see may not accept the need for change. There may be
Ways Teaching Can Cause Problems in Chap. 15. a lack of motivation because they do not realize
the benefits to be attained through education. Or,
compared to other events, they may regard learn-
14.8.4 Sociological and Emotional ing as being of low priority. Thus learning is
Factors affected by past experiences, current socioeco-
nomic situation, social norms, habits, beliefs, and
People learn when they have a reason for learn- anticipated outcomes of behavior [41].
ing. Those with asthma must have a reason or Health beliefs play a major role in a person’s
motivation for learning about asthma. Without attitude toward learning. For instance, many
motivation, learning will not take place. One of individuals hold the common but inaccurate
the primary reasons that those with asthma are beliefs that:
not interested in attending classes on asthma is
the fact that they see no need for asthma educa- • Medication is addictive.
tion. They accept having symptoms as being part • Medication is unsafe to take for long periods
of asthma, and they learn to live with the disease of time [42].
without expecting any possibility of improve- • Regular use of medication decreases its
ment. They do not know that they can learn to effectiveness.
control the disease and that education can make
the difference between simply existing and living It becomes the task of the asthma educator to
a full and normal life. Their expectations are that discover the person’s health beliefs and to gently
asthma will limit them, and too often they will- change or correct them as necessary. For
ingly accept the limitations they themselves instance, asthma medications are neither addic-
impose due to lack of education. The asthma edu- tive nor do they decrease in effectiveness over
cator then has to change their expectations and time. They are safe to use, and a simple explana-
teach them that they can live a normal life while tion of the quantity of inhaled steroids (measured
taking certain precautions. in a thousandth of a milligram or a millionth part
People learn in different ways. Some are per- of a gram) will often reassure them. Many peo-
sistent and can learn on their own, while others ple do not understand what a microgram is, and
may require constant encouragement and gentle a clarification can often ease their fears.
supervision. Some may function best when learn- Resistance is further reduced when explaining
ing with another, or in a group, or with their that the corticosteroids prescribed by the physi-
peers. Often individuals and their families have cian or healthcare provider are similar to the ste-
other worries that affect their ability to learn. roids that the body produces—not the illegal
There may be financial concerns, work schedules anabolic steroids used by weight lifters, body
that require alteration, living situations that must builders, and athletes.
be adjusted, work environments that need to be Attitudes are influenced by family, associates,
changed, and even the possibility of job loss. media, experience, authority, persons in a posi-
tion of trust, religion, and culture. Certain other Hence the disease itself and its level of severity
health beliefs, which may conflict with the may raise barriers [44].
Western approach to medicine, may also exist The person’s attitude to the disease, and their
because of ethnic and cultural influences. (See current emotional state (including anger and
also Chap. 11.) depression), also affects learning. Much depends
Feelings, like culture, can be a barrier. Feelings on where they are in the continuum of the dis-
are harder to ascertain, and judicious questioning ease, whether recently diagnosed or familiar with
may be necessary to elicit an individual’s senti- the disease. Their age and the length of time they
ments. Feelings are often a response to the unspo- have had the disease are also factors in accep-
ken components of a situation. tance. A recent change in severity commonly
They may: affects emotional state.
If family support is lacking, they will have dif-
• Feel they are wasting the health professional’s ficulty coping. They may be willing, but the lack
time and so will not ask for clarification. of support may make endeavors ineffective and
• Be reluctant to admit they do not understand increase both anxiety and lack of control. So
what is being said, particularly if technical while they are motivated, the barriers created by
terms are used but not explained. the lack of support are formidable. Family and/or
• Omit details they consider unimportant or personal counseling becomes imperative. This
unrelated. needs to be approached with care: even when a
• Be embarrassed to mention items they feel family is very unsupportive, there may be added
will make the educator view them in a nega- resentment when an outsider points it out.
tive light. Again, the person with asthma may see sec-
• Believe that they were not understood or lis- ondary gain [45] in failing to use the information
tened to; hence, any given instructions were provided. Secondary gain is defined as the bene-
not important. fits the individual receives from being ill. This
• Be defensive about their lack of knowledge. may include increased attention from the family,
and decreased pressure to work or perform well,
There may be other psychological barriers with the disease providing an acceptable excuse
[43] that determine a person’s attitude. These to avoid any form of endeavor.
must be assessed before teaching can occur. They Adolescents list their barriers to compliance
may be angry, fearful, and mistrustful as a result [46] as inconvenience, lifestyle changes that are
of past experiences with the healthcare system required, social embarrassment, and side effects
and/or have unrealistic expectations or goals. from medication, especially steroids, in that order.
Expectations and goals must be tailored to meet In summary, a person’s attitudes, beliefs, con-
the limits imposed by asthma. cerns, feelings, and ability to cope can all be bar-
Some psychosocial factors to consider include riers to learning. Since every person presents a
the following: different constellation of problems, the educator
must approach each one as a unique individual.
• Anxiety/fear Knowledge of the barriers that exist is a precursor
• Family cohesiveness and support to understanding how they think and learn. It is
• Stigma attached to taking medication necessary to understand them before a teaching
• Dysfunctional families plan can be devised.
• Specific fears (e.g., steroid phobia) Self-help is a behavioral goal and they must be
allowed to develop a feeling of self-control. They
Individuals unable to cope with the variability must also be allowed to determine their own pri-
of asthma feel powerless and helpless. Lack of orities and their own level of risk combination
family and social support together with unpre- [40]. Individuals with asthma do know what they
dictable exacerbations may make coping so dif- want and need guidance in achieving what they
ficult that corrective action is not even initiated. know they need.
14.9 Principles of Learning minimized. Learning will take place more readily
when anxieties and fears are at a minimum.
From this basic understanding of learning theo- The challenge of learning something new is
ries, the methods and styles of learning, and the often seen as threatening. A degree of anxiety
barriers to learning, it is possible to derive certain prevails when a person is faced with unfamiliar
basic principles of learning [3]. material. Anxiety is related to attention and to
These are: motivation and is also generated by the decision-
making process. Anxiety impairs memory, atten-
1. Perception is essential for learning. tion, concept formation, learning,
problem-solving, and even the performance of
The educator must use a variety of methods, simple tasks.
recognizing that individuals learn in different The educator must also understand that any
ways. The more senses involved in learning, the type of anxiety affects the individual’s readiness
greater the degree of learning that takes place. to learn. If they are eager to learn but have a high
For example, giving them a peak flow meter to level of anxiety, then no matter how effectively
hold in their hands is far superior (in terms of the information is presented, they will, at best,
teaching) than asking them to imagine a peak only partially retain the information or, at worst,
flow meter. misconstrue it because attention was not fully
When teaching about a device, the use of differ- focused on what was being taught.
ent sensory approaches such as pictures, video Anxiety can be reduced by anticipatory
presentations, and actual demonstration—all lead- guidance, as, for instance, in preparing the
ing up to the point where they can demonstrate the individual for what happens during an asthma
use of the device—will lead to a greater under- exacerbation and how to avoid it. Anxiety in
standing of how the device is to be used, together learning to use a device can be minimized by
with its accompanying “dos” and “don’ts.” instruction and preparation, increased use of
The more “hands-on” an approach that can be feedback, and reduction of any possibilities of
taken for the purpose of teaching (as in the use of failure.
any of the devices required for asthma medica- Hence the teacher is required to provide an
tion), the more successful the outcome. environment that is conducive to learning and to
Perception is crucial for learning. A peak flow the exchange of information while reducing any
diary is useless for a person with a low literacy barriers to learning.
level or for one who cannot differentiate between
the red- and green-colored zones. The latter can 3. Learning is more effective when it is in
easily be overlooked. Ten percent of the popula- response to a need defined by the individual.
tion, mostly male, has a problem with color per-
ception. Red-green color blindness is the most Providing information that the person does not
common. Many men are not aware of their color require or cannot use immediately is a waste of
blindness, so educators should be aware of this time for both the teacher and the person with
potential problem. asthma. Information that meets the individual’s
In the older adult, the aging process hampers needs will have a greater chance of being accepted
perception, and hence large print and clear dic- and used than information that does not satisfy a
tion are necessary to aid perception. need or assuage a concern. Hence all learning and
teaching should be on a needs-based approach.
2. Anxiety reduces the person’s ability to focus. For instance, telling an individual how to cope
with exercise-induced asthma (EIA) is pointless
It also affects the readiness to learn. Any if exercise is not a trigger. There is widespread
source of pressure such as time constraints, recognition that adults (and children) in Western
choice of site, fatigue, or other factors must be societies are, in general, very inactive. No matter
how great the desire to change this, the reality is questions before, during, and after teaching is a
that many adults seen by an educator have no form of repetition that increases the degree of
interest in exercise. learning.
Chapter 10 outlined the requirements and A person’s level of understanding and of
process for the initial and follow-up visits. It is knowledge requires periodic assessment.
important to remember that the needs and Knowledge will increase or decrease with the
responses of each individual will determine passage of time. Knowledge that is not used is
whether the initial plan is carried out in its com- forgotten. People with asthma are also exposed to
plete form or whether the plan is truncated, a variety of sources of information, particularly
abbreviated, or even discarded. Hence the teach- on the Internet—some good, some bad. There
ing process is dependent on the needs and con- may even be times when misinformation will
cerns of the individual and requires a great need correcting. Thus, the asthma educator must
degree of flexibility in accommodating those frequently assess the individual’s current level of
needs and concerns. knowledge.
4. Learning is expedited when it is related to 6. Learning is easier if the learner understands

what the learner already knows. the underlying purpose of the information.
This decreases the level of anxiety since the There are many aspects of asthma that can be
learning is seen as an extension of current knowl- taught to the individual with asthma. For success-
edge. Hence, an assessment of the individual’s ful learning to take place, however, the individual
level of knowledge and understanding is required must feel that the information is likely to be help-
so that the educator can build on existing knowl- ful in either reducing a risk or providing a benefit.
edge. Establishing a connection or association Information that answers specific needs is the
between a new concept and one that is familiar best motivation.
accelerates the learner’s understanding and Individuals with asthma are more likely to
enhances learning. learn if the purpose underlying the teaching is
Asking individuals with asthma to visualize clearly explained. Purposeful learning motivates
the “traffic light system” for asthma manage- individuals, particularly adults, to try certain
ment, and correlating that with the three asthma behaviors. Motivation is a function of a desire to
zones, can help them understand how peak flow excel and of the expectation of success and can
monitoring is helpful in the control of asthma. result from any incentives that are provided.
Because this information is associated with the To summarize: any information given to the
red-yellow-green traffic signals, understanding is individual with asthma must pass the crucial
simplified and learning is strengthened. “what’s in it for me?” test—the person must see
Association is an important learning strategy. the need for the information.
5. Learning is enhanced by repetition. 7. Learner control increases learning.
Continuous validation of the information, Providing individuals with a feeling of control

together with constant updating and reexposure, in the learning process accentuates the sense of
will facilitate the assimilation of the information being in control. This can be done by treating
presented. Repetition, review, and reinforcement them as a member of the team who has a say in
all make learning easier. Periodic practice allows determining the defined goals, the medication
for the improvement and maintenance of skill regimen, and the asthma action plan. This input
levels. Repetition that uses the same words will provides them with a sense of control. Allowing
give rise to boredom. Repetition that involves the them greater control also instills a sense of
use of different senses will help them. Asking responsibility in them to manage their disease
and helps develop self-efficacy—the belief that meter than someone who does not see the need
they can manage their asthma which is crucial for for it. The individual can now choose, knowing
self-management. the options available, whether or not to maintain
A sense of helplessness and powerlessness a diary. The educator must allow this individual
may follow from the variability of asthma, and to make this decision once they are made aware
this may create further problems for them. of the choices.
Individuals with asthma who are able to cope, When the person sees a personal benefit to the
and who feel in control over the current status of information, there will be a desire to use the
their disease, are more open to learning and try- information. So while responsibility for learning
ing new behaviors than those who feel helpless rests with the learner, it is the educator’s job to
and uncertain. The feeling of being in control motivate the learner.
allows them to learn how to cope with the disease
and its varying stages. It reduces their level of 10. Material must be presented in a logical,
anxiety and makes them more receptive to infor- organized sequence.
mation. Anything taught to them that is clearly
geared to maintaining or achieving control of When information is organized in a series of
asthma will stand a better chance of being logical steps (as in how to use a device), graded
accepted than information that promises control from the simple to the complex, the individual
without defining the means. will learn quickly, retain the information easily,
and be more willing to apply it. Teaching then
8. Immediate application allows learning to be requires a planned design. It must also be well
retained. organized both as to content and to fit the learn-
er’s needs. The organization of material affects
Learning that can be put to immediate use is the way information is processed and retained
remembered longer than when its application is and the degree of learning.
delayed. It is necessary to provide the individual
with opportunities to apply information as 11. Learning must be reinforced.
quickly as possible in order to develop the associ-
ated skill. For example, learning how to interpret Review and repetition are two ways in which
a peak flowchart and its zones is extremely useful reinforcement can be provided. In asthma, the
if the person is currently keeping an asthma PEF most consistent requirement is the need to review
diary. The person can apply the knowledge to the use of the asthma medication devices. Studies
interpreting peak flow variations, which in turn have shown that technique deteriorates in as little
will lead to the development of prevention skills. as 2 weeks. Hence it is helpful for the person with
asthma if the use of their device is reviewed on
9. Responsibility for learning rests with the each and every visit to the healthcare provider or
learner. health professional. It takes a minimum of three
periods of instruction to develop the necessary
This is best understood through a simple inhalation skills [47].
example. Individuals with asthma are taught to Repetition is a method of reinforcement.
use a peak flow meter and to chart their readings Information heard often enough becomes famil-
in a daily diary. With the peak flow diary provid- iar and is easily accepted. For example, individu-
ing feedback, the individual is more likely to als with asthma are very often reluctant to use or
want to use the peak flow meter because self- purchase a spacer or holding chamber because
observation proves that use of the peak flow they find it expensive or too bulky or awkward to
meter helps in monitoring asthma. It also pro- use. They may have other reasons for their reluc-
vides a means of control. In this case, the indi- tance to use an additional device. However, if the
vidual will be more likely to continue using the asthma educator habitually informs them that a
holding chamber or spacer will increase by up to and they will feel in control of what has been
33% the amount of medication inhaled, reduce taught. For some, too much information may
medication wastage, and prevent thrush, then reinforce their belief that asthma is too difficult
they may be more inclined to use the holding or too complicated for the lay person to handle
chamber or spacer and consequently receive the and that management of the disease is best left to
many benefits of this device. specialists.
Reinforcement can take many forms, includ- Different individuals can manage different
ing reward, recognition, review, repetition of new amounts of information. Much depends on their
skills, constructive feedback, encouragement, or particular situation at that moment in time. The
a heartfelt compliment [48]. Often a simple “well amount provided will vary with each one; for the
done” said sincerely will suffice. same person, it can even vary from one session to
the next, depending on a number of factors that
12. Learning is facilitated when the learner is can raise barriers.
aware of progress. Learners need time to practice and to know
how to apply the knowledge gained. When they
Awareness can be defined as knowledge of realize for themselves how they have benefited
improved skills, a positive attitude, satisfaction from the knowledge, that realization will often
from an increase in knowledge, a perceived ben- lay down the foundation for a change in
efit, or even a realization that “it feels good.” behavior.
Positive feedback from the educator allows this
growth of awareness and permits the learner to 15. Active participation is essential for
approach learning with anticipation rather than learning.
reluctance.
A multisensory approach will further intensify
13. Plateaus occur in learning. the level of participation. A passive listener is
unlikely to retain information, while a learner
The initial rapid increase in knowledge is who is provided with an actual hands-on level of
followed in due course by a lull or plateau, participation, whether verbal or tactile, will learn
where progress appears to be at a standstill. more quickly and easily. Leaning requires
This is then followed by a less rapid increase in involvement. For example, a person who is
knowledge. While the rate of progress does encouraged to discuss fears about steroids is par-
increase, it does not equal the initial rate. In ticipating actively, as opposed to one who listens,
time, yet another plateau is reached, and this but leaves confused about the usefulness of ste-
pattern tends to repeat itself. This is a normal roids in the control of asthma.
cycle in learning. The rate of learning does not A hands-on approach will also simplify the
remain constant. development of new skills. The individual who
However, stress and the difficulty of coping actually practices with a peak flow meter is more
with the variability of asthma can also cause pla- likely to understand how effective this device can
teaus. A variety of factors influence learning, and be in monitoring asthma than one who merely lis-
neither educator nor learner should feel discour- tens while the educator demonstrates its use.
aged when progress is constrained. Active participation also requires that the learner
be focused. This demands mental concentration
14. Pacing of content is conducive to learning. and mental activity.
This chapter and these basic principles (see
Too much information causes information Fig. 14.9) form a distillation of the many con-
overload, with very little retention. Information cepts and theories of learning. Teaching requires
that is well-spaced, and that allows time for an awareness of all these concepts. It also
assimilation, use, and practice, will be retained, demands that the educator have an understanding
4. In Chap. 17, do case studies 11 and 12.

Learning is fostered by
Perception
Motivation
Repetition References
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Teaching the Person with Asthma
15
Contents
15.2 Teaching Approaches for Different Audiences 517
15.2.1 Parents 517
15.2.1.1 Attitude 518
15.2.1.2 Asthma Diary 519
15.2.1.3 Parents Are the Child Experts 519
15.2.1.4 Warning Signs 519
15.2.1.5 Asthma Plan 519
15.2.2 Children 520
15.2.3 Adolescents 522
15.2.3.1 Independence 522
15.2.3.2 Rebellion 522
15.2.3.3 Peer Pressure 522
15.2.3.4 Adherence 523
15.2.3.5 Teaching Approach 523
15.2.3.6 Adolescent Concerns 524
15.2.4 Adults 525
15.2.5 Low-Literacy Individuals 527
15.2.6 The Older Adult 528
15.2.7 Response to Education 530
15.2.8 Cultural Competency 530
15.2.9 Mobile Applications for Asthma 532
15.3 Teaching Methods 534
15.3.1 The Individual 535
15.3.2 The Small Group 536
15.3.3 The Large Group 537
15.4 The Process of Education 538
15.4.1 The Cognitive Domain 539
15.4.2 The Affective Domain 540
15.4.2.1 The Affective Domain and Chronic Illness 541
15.4.3 The Psychomotor Domain 543
15.5 Planning for Teaching 544
15.5.1 Assessment 544
15.5.2 Planning 546
15.5.3 Planning for the Affective Domain 546
15.5.4 Planning for the Cognitive Domain 547
15.5.5 Planning for the Psychomotor Domain 547
516 15 Teaching the Person with Asthma
15.5.6 I mplementation 548

15.5.7 E valuation 548
15.5.8 S ample Teaching Plans 550
15.6 The Role of the Educator 551
15.6.1 Principles of Communication in a Consultation 551
15.6.2 Setting the Climate for Teaching 552
15.6.3 Ways of Teaching That Can Cause Problems 554
15.7 Teaching Strategies 556
15.8 The Team Approach to Teaching 562
References 564
Key Points
• The role of the educator is emphasized,
• Education is much more than along with the principles of
information. communication
• Educational approaches differ: –– Ways in which teaching itself can
–– At different life stages. cause problems are described.
–– For varying literacy levels. • The team approach to teaching is best.
–– For different cultures. • Strategies to aid the educator and the
• Teaching apps also affect the educa- clinic staff to work together are listed.
tional process.
• The teaching method used will vary
depending on whether it is done indi-
vidually, in a small, or a large group. Chapter Objectives
–– Group dynamics affect the educa- After reading this chapter, you should be
tional process. able to:
• Domains of learning—the cognitive,
affective, and psychomotor—are 1. List the different approaches that should
important. be considered when working with indi-
–– They allow individuals to be effec- viduals of different ages
tively targeted. 2. Define the three domains of learning and
–– The affective domain plays a major how they relate to planning for teaching
role in persons with a chronic condi- 3. List the ways in which teaching can

tion such as asthma. cause problems for a person with asthma
• Teaching requires planning for the three 4. Plan a lesson for either an individual or
domains, and for implementation and a small group, and define the method,
evaluation. techniques, and aids to be used to
–– Sample teaching plans are provided. achieve a particular objective
15.1 Introduction stages of life, including parents of children with

asthma, children, teenagers, adults, individuals
The basic principles underlying a successful with low literacy, and older adults.
teaching session remain unchanged across all
disciplines—whether the session is for a class of
university students attempting to understand 15.2.1 Parents
nuclear physics or to a worried person newly
diagnosed with asthma. However, while the prin- While all parents are concerned about their chil-
ciples do not change, the method used has to be dren who have asthma, some have more prob-
adjusted to meet the needs of the audience and lems than others in following medical advice. A
that is the secret to success. People with asthma small number will not change their habits or life-
need to be educated in order to know that exacer- style, even if these are harmful to the child. Some
bations do not happen unexpectedly, that the will be unable to stop smoking in the house, or
asthma can be controlled, and that they can live a unwilling to move a pet outdoors. Sometimes the
normal life. educator will suspect that certain parents do not
As mentioned in earlier chapters, studies have take even basic steps to help the child. Such par-
clearly shown that knowledge alone does not ents will pose a challenge, and the asthma educa-
change behavior, and in asthma, education really tor will have to work with them to understand
makes the difference. both their point of view and why this is happen-
Since asthma affects people of all ages, as ing. At times like this, it is helpful to remember
well as parent of children who have the condi- that behavior changes are most likely to occur if
tion, different teaching approaches have to be a good relationship is maintained with the
used for each group, different teaching methods parents.
employed, and different teaching plans devel- Any educational approach (or teaching strat-
oped. Of all these requirements, planning is the egy selected) must take the parent or major care-
most important. giver’s intellectual ability into consideration. In
Rather than starting with a discussion of les- the past, mothers were almost always the sole
son and teaching plans, this chapter begins with caregivers, responsible for medical issues in chil-
the end result—the different teaching approaches dren. Today, there is greater recognition that
to be used when presenting asthma to different fathers must also participate in all aspects of care,
audiences. Once these are understood, a teaching and they are now more likely to do so, and per-
plan can be developed for each audience. mitted to do so, than in the past. There is now a
From the teacher or educator’s point of view, greater variation in family structure. At the least,
individuals with asthma are students, but just a mother-mother and father-father dyads have
very special type of students, and they are often joined the old father-mother dyad. There may be
referred to as such in this chapter. other important caregivers, such as grandparents
or baby sitters, all of whom must be well informed
about asthma to achieve a good outcome. So, it
15.2 Teaching Approaches cannot be assumed that the mother is the only
for Different Audiences person with whom the asthma educator will have
to work. An awareness of how the family oper-
The success of a teaching session depends to a ates is required, as is acceptance of the roles they
large extent on the educator’s approach. This sec- choose.
tion suggests approaches that can be used with Pediatric care has historically relied on mater-
individuals of different ages and in different nal awareness for differential diagnosis and on
maternal ability to follow a prescribed regimen, child relationship, the level of parental anxiety,
especially in the early years. These are important and the degree to which the parents are willing to
factors in adherence. Previous studies have be involved in the care of their child. There are
focused on mothers, but the findings may apply other issues to be considered with single-parent
to whoever is the major caregiver. For example, families where sole responsibility for the care of
mothers with intellectual disabilities [1] may be the child lies with one parent (usually the mother).
lacking in parental skills such as organization, These families tend to have:
supervision, interaction, judgment, and disci-
pline. They may be unable to monitor their chil- • Financial problems
dren’s symptoms, to report those symptoms, or to • Little or no access to supplementary
judge when the child needs medical attention. caregivers
They may be incapable of understanding the seri- • Little support, financial, or otherwise
ousness of a disease such as asthma and ignore
the child’s symptoms. They may be inept at fol- Medical appointments require time off from
lowing a daily routine, let alone something as work, and a chronically ill child with asthma may
complicated as an asthma plan. drain all the scarce resources of the family. The
They may also appear to agree and concur burden of care cannot be shared and finding
with the physician or healthcare provider’s rec- appropriate childcare is difficult if not impossible
ommendations, and may even wish to do so, but in the circumstances under which single-parent
leave the teaching session with only a vague idea families labor.
of what they need to do. Despite the best of inten-
tions, the task may be beyond their ability. 15.2.1.1 Attitude
Their children tend to be undisciplined, poorly As there is a major genetic component to asthma,
supervised, and inadequately nourished and have many parents also have asthma, and/or have a
poor attendance at school. They are likely to be close relative with asthma. They may have
late for appointments since they often cannot acquaintances with asthma, and may have formed
judge time or estimate the time required for a view of asthma based on their experience with
travel. one or two individuals.
When also in a state of poverty, all of the Some parents first encounter asthma when
above conditions are complicated by a lack of their child is first diagnosed. Whatever their
money for proper food, for professional medical background knowledge and understanding of
care, for medications, and for corrective mea- asthma may be, it is essential to discuss their
sures in the home that might alleviate asthma questions and fears calmly. The educator must
symptoms. Some families may be unable to fol- adopt a positive approach, but one that does not
low directions; understand complex medical regi- minimize the consequences of having asthma [3].
mens; report medical problems properly; provide The long-term nature of asthma must be empha-
complete medical reports; and read, recall, or sized, lest they feel that child can be (or has been)
repeat instructions. In such cases even more care cured after just one episode.
than usual needs to be taken to include fathers Parents must be helped to understand that
and other extended family members in the educa- their child with asthma needs their love and care.
tional program. More attention must be paid to The child doesn’t need parents who are over-
these families, and a detailed review of their confident, and avoid professional help, nor par-
needs must be made. The problems identified ents who are over-indulgent, or over-protective.
may be common in other family members. The social experiences of the child should not be
However, it must never be assumed that a family restricted nor is there a place for unnecessary
in poverty will also lack intellectual ability. pampering that will unconsciously encourage the
Some other factors [2] to be considered are the “sick role.” If a parent wishes to be overprotec-
nature of the family’s relationships, the parent- tive, the success of Olympic athletes with asthma
(who were not over-protected by family, and thus 6–8 year group will be able to discuss their symp-
not barred from realizing their ambitions) can be toms and feelings about treatment. Early adoles-
mentioned. Parents must be helped to understand cents will emphasize the restrictions on their
that asthma is a medical condition. Neither guilt lives and list all the things they cannot do. It is
nor blame is an accurate or useful emotion. A only in late adolescence that the child can accept
positive attitude is essential in the management the chronicity of the disease [6].
of the disease.
The level of education of the main caregiver is 15.2.1.4 Warning Signs
a major determinate of the child’s health status Small children have their own special ways of
[4]. The more educated the caregiver, the more signaling approaching asthma attacks. These
the likelihood that the medical regimen will be may include complaints of tummy-ache. Since
maintained, and the greater the chance of work- children cannot tell where their chests end and
ing with them as a team to manage the child’s their stomachs begin, this can be a legitimate
asthma. warning sign. Itching, rubbing of the throat, a
sensation of heat, redness, vomiting, chest pain,
15.2.1.2 Asthma Diary tightness, reluctance to play, and becoming with-
Once the educator has explained the benefits of drawn and quiet—all these can be warning signs.
an asthma diary as a way to identify triggers, (This is also discussed in Chap. 1.) Each child is
most parents will be willing to maintain a diary different and will have different warning signs;
for a few weeks. This will be a major help to the fortunately for the healthcare professional, how-
parents—and to the asthma educator—on their ever, there are some distinct patterns.
next visit. At that time, they may need help to A parent with two children with asthma should
recognize the pattern of asthma that their child not expect that they will both have identical trig-
exhibits. It may be as simple as recognizing that gers or warning signs. The simplest way to recog-
a visit to a neighbor is the cause of an attack, and nize warning signs is by being attentive to the
from that understanding may come the realiza- child and watching for any behavior, complaints,
tion that exposure to conditions (such as a pet or or actions that are not normal for this child [7].
cockroaches) in someone else’s home is a cause One or more of these could be a warning of
for concern. asthma. By recording the child’s complaints or
behavior, the parents can soon learn to distin-
15.2.1.3 P arents Are the Child guish between signs that can be ignored, and
Experts those that should not. Once parents are aware of
Remind parents that nobody knows their child as the signs, they will rapidly gain confidence in
well as they do. The asthma educator and the their ability not only to predict an asthma attack
healthcare provider will see the child only occa- but also to control it.
sionally, while the parents live with the child all
day, every day. Parents must learn to trust their 15.2.1.5 Asthma Plan
judgment and “gut feeling” in all matters con- Most parents will be reluctant to treat or manage
cerning the child’s health. They should not hesi- an asthma attack at home. Initially, they will lack
tate to take the child to the healthcare provider or self-confidence. Reassure them that they can do
clinic whenever they have health-related so, and that they will, in time, develop the skills
concerns. needed to control their child’s asthma. It is the
Since small children cannot use peak flow function of the asthma educator to help them gain
meters, it is essential that the parents watch for the necessary confidence. Constant reassurance
symptoms and note them in a diary. This will will help them believe that they can do the job.
allow them to identify their child’s triggers. Parents must have confidence in an action plan
Parents should be aware of how their children that is compiled with their cooperation. They will
feel about having asthma [5]. Children in the be prepared to put the plan into practice if they
understand it, and the simplest way to obtain take trips like other children. They should be
their understanding is by getting their help when treated as any other child, just one who has to
preparing it. As their confidence increases, they take some precautions to prevent attacks.
will be more willing to work with the asthma Treatment-related concerns include:
educator and the healthcare provider.
• Remembering to take mid-day medications
(these can be avoided with careful selection of
15.2.2 Children medication)
• Handling exercise-related problems, particu-
The concept of illness is understood only with larly in physical education classes
age and experience, particularly by children. • Recognizing symptoms and requesting
Children with a chronic illness have a greater treatment
understanding of bodily functions than other • Avoiding triggers, particularly at school
children [8]. Changes in conceptual understand-
ing that occur in the concrete operational phase Children should be given appropriate knowl-
(Piaget’s 7- to 11-year category) are far more dra- edge about their asthma and their expected role in
matic than during other phases [9]. By the age of its management [12, 13]. They may need to be
eight, children can identify and enunciate disease- reassured that they are not responsible for having
related problems; they can also use problem- the illness and that nothing they did resulted in
solving techniques that they are taught [10]. the asthma or allergies. While children may occa-
Changes in understanding continue during ado- sionally forget to take their medications, they will
lescence but are slower [8]. Thus, as they grow, often avoid taking or asking for their medications
children increasingly understand the cause and in public, so as not to be “different.” Children are
development of disease. reluctant to interrupt their play in order to take
Psychosocial problems that include poverty, medication, yet there are times when it is neces-
hunger, a dysfunctional family, emotional or psy- sary that they do so. If medication is always
chological issues, psychiatric disorders [11], and accompanied by a hug and cuddle from the par-
inadequate educational resources can all make it ent, the younger child will be less reluctant to
difficult for children to learn. The educator must take medication. If the child for some reason can-
be aware of these possibilities, and of the current not use, or has not been prescribed an MDI, the
state of asthma in the child, the side effects of any more time-consuming nebulizer will have to be
asthma medications, the use of anti-histamines, used. The time with the nebulizer can be used by
and their impact on the child’s ability to learn. the parent to read to, or to play a board game
There are four issues for the child to deal with: with, the child—i.e., to perform some joint activ-
ity so that the child does not consider time spent
• Acceptance of asthma with the nebulizer as time wasted or as a period
• The problem of being “different” of isolation from the rest of the family.
• The need for medication However, an MDI with a spacer or valved
• Participation in all activities holding chamber is as effective as, or more effec-
tive than, nebulizers. If there are behavioral
Acceptance is difficult if there is little or no issues with the nebulizer, an adjustment in the
support from the family, particularly in the area medication regimen, that is, the use of an MDI,
of trigger avoidance. Many children experience can help.
anger and ask, “Why me?” They will need to be Avoidance of triggers can be a problem for
reassured that they are no different from other children, particularly if there are smokers in the
children with asthma. They should have no house. It is often helpful to ask questions of the
restrictions on their play or exercise and should child such as “Is there cigarette smoke near your
be allowed to feel normal, go to summer camp, or house or in your house?” The child will then tell
you if someone else in the family smokes. Pets tions be locked up in the principal’s office. This
can be a major problem, with both parent and can put children at risk.
child reluctant to arrange for a new home for a Children whose parents are both involved with
loved pet. In addition, a sibling without asthma the child but who do not live together for what-
may feel it is their right to have a pet. Eliminating ever reason require additional help. The legal
or minimizing exposure to triggers can be major arrangements need to be clear to the school: Is
problems if family members, including grandpar- there joint custody and joint decision-making? Is
ents, do not understand, or never accept, the there joint custody, but one parent has sole
importance of avoidance in disease authority to agree to medical treatment? Whatever
management. the legal niceties, it is essential that both parents
Recognition of symptoms is a major issue be informed and educated so that the child’s psy-
with children and adults. Asking the child to chosocial development and medical care are not
describe feelings just before an asthma attack hindered [7]. However, it is not the role of one
will also enlighten the parents. It will help them parent to educate the other on the child’s asthma
recognize the child’s symptoms so that quick regimen. There may be differing parenting styles,
action can be taken. with one aiming to give the child excellent care
Since asthma is a common disease in school, only to be seen by the other parent as over-
with more than 10% of schoolchildren suffering protective. By contrast, attempts by one parent to
from it, teachers must be given information about foster independence may be seen by the other as
asthma and its symptoms. They must be educated negligence. Such variations in parenting are seen
about all the implications of asthma, so that they just as often in so-called “intact” families.
will believe a child with asthma when that child Whatever the details, the educator must get
complains of feeling unwell. The variable nature involved in teaching both parents for the sake of
of asthma must also be clearly described so that the child. The child too will require help in
teachers realize that a child will not perform adjusting to such a situation, and the educator,
equally well at different times, and that two chil- with the team, can do much to minimize the neg-
dren with asthma will rarely have identical symp- ative impact of such situations.
toms. Participating in physical education classes Children who are frequently hospitalized and
and other activities may be a problem at some have severe asthma feel more lonely [14]. Their
times for all children with asthma. Exercise- peer relationships are also affected, and this gives
induced symptoms are almost universal in chil- rise to greater concern than for children with few
dren with asthma, especially if overall control is or no admissions. They are also at higher risk for
suboptimal. poor academic performance [15]. Frequent
Teachers very often do not understand that admissions are not necessarily indicators of
these children cannot perform consistently from severity per se. They may be associated with psy-
day to day, or that performance can vary from chosocial problems or lack of money to pay for
hour to hour, depending on the level of allergen medications, for example. In addition, children
exposure. They must be made aware that the chil- with asthma often feel isolated, ignored, and gen-
dren’s performances will vary depending on their erally considered unfit for sports [16]. These are
health at that moment; that some require pre- serious stressors.
treatment before an exercise session; and that a Children whose parents are knowledgeable
slow warm-up and a slow cool-down will help to about asthma will feel competent to manage their
prevent asthma symptoms. own asthma [17]. There is also a direct correla-
Each child’s reliever medication must be read- tion between knowledge and confidence as the
ily available at all times. Most children are good child grows.
judges of when they need their medication and Parents have an exceedingly important role to
are more likely to under-use than overuse it. play in modeling decision-making in all aspects
Some elementary schools require that all medica- of life. Decision-making is an essential skill to be
nurtured in children and through adolescence ties are not the priorities of the healthcare team.
(and beyond!). As well as modeling, the parent They are reluctant to ask for help. Important
can discuss the child’s emotions and concerns, factors that require consideration are discussed
gently asking questions and encouraging the below.
child to ask questions about asthma, the treat-
ment, changes in treatment, etc. Initially deci- 15.2.3.1 Independence
sions will be made with parental guidance. This They value their independence and being allowed
allows the child to feel involved and slowly builds to make their own decisions. They do not want to
confidence and self-efficacy so that as an adoles- be told what to do. Worse, they often resent being
cent, participation and decision-making with the told what to do, whether by their parents or any
asthma team becomes a natural progression to other authority figure. They desperately want to
self-management of the asthma [18]. be treated like independent adults. They want to
participate in making decisions about their
asthma treatment but also want their parents and
15.2.3 Adolescents physician to be involved [20].
Adolescents go through physical, emotional, 15.2.3.2 Rebellion

cognitive, and social changes; and they are on the Adolescents often want to be seen as opposed to
threshold of adulthood, soon to have full respon- all the values and beliefs their parents stand for.
sibility for their own health. They will be parents They want to be different, to find and establish
soon. They need specific help in navigating these their own identities. They enjoy being rebels in
life transitions, at the same time learning how to some form or other. Rebellion will often take the
manage a chronic illness by themselves. Many form of doing the opposite of what their parents,
professionals dealing with adolescents find their or adults in a position of authority, request.
special needs daunting, and dealing with them Despite knowing the consequences, they will
may seem an impossible task. We provide some often act in defiance because, in their order of pri-
helpful guidance for the educator that may turn orities, independence, as expressed through
this into the most satisfying professional task. rebellion, is more important than staying healthy.
Briefly, adolescents go through three stages
[19]: 15.2.3.3 Peer Pressure
They want to be different from their family mem-
• Early adolescence: 12–14 years. They are bers. Yet, at the same time, they need to conform
keenly aware of physical changes due to to their peer groups. Hence, they will do anything
puberty. to be accepted by their peers. Many teens smoke,
• Middle adolescence: 15–16 years. They make and many teens with asthma smoke even though
attempts at independence and challenge they know that smoke is one of their triggers.
parental authority in an effort to define their Even if they do not smoke, they are not likely to
sense of self. Peer group influence is strong. avoid smoky environments.
They still depend on parental and family Peer pressure must be given careful consider-
support. ation. Most teens will not admit to having asthma.
• Late adolescence: 17–19 years. Career choices They will do anything to keep that knowledge a
are paramount. Work, lifestyle, and long-term secret, even from their best friends. Many are
relationships are in the process of being embarrassed by their asthma symptoms and by
defined. having to take medication in front of their peers.
They feel stigmatized and different, and hence
With adolescents, there are specific issues to the need to hide their asthma. If they consider
watch for. They tend not to look after themselves, taking medicine in public to be unacceptable,
which is another way of saying that their priori- they will be reluctant to do so. They are fearful of
rejection or isolation by their peers because of 15.2.3.5 Teaching Approach

their asthma. Adolescents must be treated with honesty and
respect by all professionals. Confidentiality is an
15.2.3.4 Adherence important ethical value, to be observed by all
As in every aspect of adolescence, in terms of healthcare providers. This value should also be
adherence, the seeds of success or failure are upheld by the asthma educator. It would be help-
sown years earlier. Adolescents who have been ful to determine what the adolescent wants to do
involved in decision-making as children will par- by discussing—first with the adolescent and then
ticipate with comfort in medical encounters. with the parent—whether or not the adolescent
They are more likely to be confident in making should be seen alone. Ideally, there should be a
guided decisions and to be adherent [14]. Their period with just the educator and the individual
decisions will tend to focus on the immediate with asthma. As a word of caution, the law varies
treatment, its benefits, and effects on their quality from state to state in terms of adolescent indepen-
of life and not on the long-term view of the deci- dence in healthcare issues. The asthma educator
sion [21]. should be familiar with the law in their geo-
Teenagers dislike the unpleasant feelings and graphic area. However, in practice, most parents
emotions which are side effects of the asthma, will accept that an adolescent seen by themselves
and sometimes of the medication. Further, they with an educator is one way of encouraging the
detest having restrictions placed on their social adolescent to take responsibility for their health.
life. One in three teens has difficulty in accepting The asthma educator should lend a sympa-
the diagnosis of asthma [22]. They tend to over- thetic ear, be willing to understand each individ-
use their bronchodilators; to remain in high-stress ual situation, and try to see the adolescent’s point
situations or environments; and to not seek medi- of view. The asthma educator should be aware
cal help in the firm belief that since they survived that compliance may be episodic and move from
the last asthma attack, the next will be as easy to total noncompliance to periodic compliance [23].
handle. They particularly dislike taking oral cor- The adolescent should be treated as a responsible
ticosteroids because of the side effects, for they young person and allowed to make a choice once the
are sensitive and vulnerable when it comes to alternatives have been clearly laid out. Teenagers are
their own appearance. Paradoxically, oral corti- more willing to listen if a feeling of trust and respect
costeroids may be required because of continued is conveyed by the asthma educator.
exposure to known triggers or failure to take pre- When talking to teenagers and young adults,
ventive treatment regularly. familiar analogies should be used. For example,
Teen adherence can be considered in terms of effective treatment of asthma may be compared
three distinct areas: with owning and driving a car: driving requires
knowing something about the car, being able to
1. Medication and the teenage lifestyle. Teens respond appropriately to traffic signals, planning
are reluctant to take medication, and to be a route so as to get to a destination quickly, and
seen to be taking it. They often rely heavily on adjusting to unforeseen situations and detours
relievers. that crop up along the way. It also requires that
2. The need to conform. This often conflicts with the car be looked after (that a maintenance rou-
the need to avoid trigger situations. tine be followed).

3. The teen feeling of immortality, otherwise Similar requirements apply to successful
known as the “It can’t happen to me” syndrome. asthma management. Individuals with asthma
By and large, teenagers do not believe they can must:
die from asthma. Since death from asthma is a
rare event, they are correct. Some healthcare • Know something about the disease
providers lose credibility by predicting events • Watch for warning signs
(such as death) which are unlikely. • Have a plan for becoming symptom-free
• Be prepared to deal with asthma emergencies • Performing problem-solving activities

that crop up together, and jointly identifying solutions
• Take care of their bodies • A simple approach to therapy, such as having
them take medication only twice a day or even
15.2.3.6 Adolescent Concerns once daily
Despite the brave show they put on, many adoles- • Coordinating medication regimen with their
cents are frightened by their asthma but will not individual lifestyle
admit their fears. A study by Bicho and col- • Allowing them to take responsibility at an age
leagues [24] found that 17% of adolescents did and maturity-appropriate level [27]
not know how to define the disease, 49% consid-
ered it serious, and 75% thought it was curable. These are excellent ways of helping a person
They feel that they are different and that of any age.
nobody understands what it means to have Non-adherence among adolescents is gener-
asthma. They are certain their problems differ ally associated with:
from those of adults with asthma. They face peer
pressure to smoke or vape, to skip medications, • A poor self-image
and to keep up with their friends in physical edu- • Poor social adaptation
cation class and in other physical activities. • Family disharmony and lack of support
Social anxiety with respect to showing symptoms • Barriers such as inconvenience, lifestyle
or taking medication tends to be high [25]. changes, social embarrassment, and side
School achievement is also affected by effects of medication
asthma. Bicho’s study [24] found that asthma • Severity of illness, where teens may try to be
was the cause of school failure in 25% of those assertive through non-adherence or may use
studied compared to the 10% level of failure in nonadherence as a call for help (because there
the control group. Asthma is a major concern for are too many stressors)
adolescents when contemplating career choices.
Their asthma is often seen by teachers as an A study by Buston found that adolescents’
excuse to get out of work assignments, or to miss reasons for nonadherence included fear of side
examinations. Having to deal with unsympathetic effects, the belief that the medication was inef-
(or disbelieving) teachers is one of the most frus- fective, denial of the diagnosis of asthma, diffi-
trating aspects of having asthma. This lack of culty using inhalers, forgetfulness, inconvenience,
understanding from people in authority is a major embarrassment, and even laziness. Too often the
problem for adolescents. adolescents “simply forgot” about their medica-
Social activities have a high priority in their tions [28].
lifestyle, and avoidance is not seen as an option, Factors that predict compliance in this age
even if they know that a particular social activity group are:
will worsen their asthma [26]. It is the role of the
asthma educator to help teenagers understand • Support from parents, healthcare profession-
that they have choices. They must be made aware als, and friends
of the range of consequences of those choices. • Motivation, energy, and willpower [29]
The asthma educator must keep in mind that
when the choices are different from what is pref- Ethnicity and culture can also be a complicat-
erable, this is not an indication of rebellion, but ing factor.
rather the result of taking a short-term view. The support network for adolescents as they
Successful techniques for dealing with teen- themselves view it includes six areas—parents,
agers involve: peers, school, healthcare professionals, technol-
ogy, and pets. Technology is very important to
• Personal contact adolescents and includes phones, computers, vid-
• Allowing them to make their own decisions eos, and television. The asthma educator can
effectively use technology to stay in touch with 15.2.4 Adults

the adolescent and vice versa [30].
Adherence in adolescents has cognitive and To some extent, adults will judge the skills of the
psychosocial components [28]. Their degree of asthma educator (and those of their healthcare
motivation is determined by the severity of the provider) by the speed with which their “most
disease and whether the locus of control is inter- urgent” needs or problems are solved. If help can
nal or external. Those who are most knowledge- be provided with these, their faith in the abilities
able about their disease and who feel some sense of the asthma team will increase, and they will
of control and autonomy are more likely to be more readily make a return visit. For example, if
compliant [12, 18]. The psychosocial factors are an adult believes coughing to be an urgent prob-
particularly important. lem, it should be addressed immediately (along
The teenager’s ability to comply may be hin- with the other asthma treatments). If the treat-
dered by a lack of support at home that can range ment prescribed reduces the amount of coughing,
from uncaring to hostile. Teens are particularly they will be more likely to return in order to
vulnerable as they seek to establish their own obtain help with other problems. In essence,
identity, and if the interaction between family because the urgent concerns were heard and
members is not supportive, this will be a cause addressed, the team gains credibility, and they
for concern. Difficult family situation may will be willing to continue working with the
require help from psychologists, psychiatrists, educator.
and social workers [31]. Family therapy may be Adults should be asked which of their symp-
required, but the family may not accept this, pre- toms bothers them the most. Which aspect of
ferring to focus on the member who is seen in the their asthma do they find the most worrisome?
family as “difficult.” Adolescents are particularly Then, they should be provided with the informa-
vulnerable in the early to middle teen years. Risk tion relevant to their problems and fears.
factors are increased by the presence of a dys- Successful teaching of adults requires that new
functional family and a neurological history with material be linked to and incorporate past experi-
psychiatric complications [32]. ences. Adults want factual information that can
The asthma educator should gently probe feel- help them make decisions, and they prefer self-
ings and note if there is depression, change in per- direction. Suggestions, rather than instructions,
sonality, bereavement, or recent loss and be aware work best: hence, a method of treatment should
if there are psychosocial issues such as moving be suggested. The educator should not instruct
house or school, absent parent, family disruption, them but, rather, work with them.
etc. Concerns with adolescents also involve exer- A study of adults by Richardson [35] listed
cise, obesity, smoking, drugs, and alcohol. five major areas of concern in both biophysical
It is in the teen years, while complex physio- and psychosocial learning needs. In descending
logical and psychological changes are occurring order of importance, they were:
in the teenager, that responsibility for treatment is
transferred from the parent to the child. Hence • Function and side effects of asthma
any effort is to be commended that enhances and medications
helps strengthen both emotional health and • Causes of asthma
adherence with the complexities of a prescribed • Ways to protect themselves and avoid triggers
asthma regimen [33, 34]. in the environment
It is also at this stage that financial responsi- • How to pace themselves during sports
bility for healthcare may be transferred to the • What happens to them (physiological changes)
older teen. Recent developments have led to peo- during an asthma exacerbation
ple in their 20’s being continued on their family
healthcare insurance. While this may alleviate These adults, aged 20–45, were most embar-
some financial anxiety, it compounds the issue of rassed by having to take medication in public and
achieving independence. reported restrictions, due to asthma, on their abil-
ity to socialize. Anger, fear, resentment, and frus- some form (even if only in an intangible form,
tration were feelings associated with asthma, and such as feeling good), then they will do it.
despite having had the disease for many years, It is also essential that adults recognize the
they still found it to be scary and frightening. importance of being candid and honest with their
About one in three of the adults found it difficult healthcare provider. They must be able to com-
to accept that the asthma was likely to continue. municate directly and must have at least a basic
The adults listed their psychosocial learning understanding of their asthma, and of the appro-
needs as follows: priate medical terminology. When talking to the
asthma educator, or to the healthcare provider,
• Relaxation techniques they must feel that they have successfully com-
• Determining whether asthma was hereditary municated their feelings or concerns, as the case
• Long-term effects may be. In turn, they must also be confident that
• A desire to obtain other persons’ perceptions they have correctly understood the asthma educa-
of asthma and learn how they cope tor and the healthcare provider.
Adults who are involved in decisions pertain-
They appear to be most interested in relaxing to their asthma exhibit improved control, lung
ation techniques because they are aware of the function, adherence, and quality of life. This
beneficial effects of relaxation on their asthma. implies starting with their stated goals and taking
Since adults are at the “generativity stage” as a holistic approach that considers their values,
defined by Erickson [36, 37], they are concerned beliefs, experiences, preferences, and priorities
about whether their children will inherit the dis- to build consensus about treatment. It means dis-
ease and to what extent their children will be cussing the benefits and risks of proposed treat-
affected by asthma or its associated conditions. ment, its side effect, and the impact of
Concerns pertaining to asthma during pregnancy comorbidities. Regular reviews and personal
include the effect of medication, particularly action plans must be devised with their input.
inhaled corticosteroids on the fetus as well as Shared decision-making is essential when deal-
fears that the child will also have asthma, and the ing with adults [38, 39].
possible degree of severity. Factors to be considered when dealing with
Adults like to find out how other adults with adults involve their perception of asthma, their
the same disease cope. They want to know the cognitive level, socio-economic level, physical
most effective methods of dealing with asthma limitations, family demands, and the support
under social conditions and when involved in available at home [2, 40]. Their literacy level
sporting activities. They want suggestions on must also be considered, simply because few
how to manage tensions induced by asthma in people read at the level of education that they
relationships with their spouses or partners. They have actually attained. Financial concerns may
want to know how to manage their emotions, be a major impediment to asthma control and
since many of the emotions generated by asthma trigger avoidance. They may or may not have
are unfavorable and negative. They are also con- supportive partners, and family demands may
cerned about the long-term effects of asthma preclude consideration of some options. Triggers
medications, particularly of steroids, as well as in the workplace will have to be discussed, and
the prognosis for asthma as they age. appropriate avoidance strategies suggested.
Most adults are willing to try something new, Some adults simply grow accustomed to the
for example, a specific new behavior or new life- restricted activities and hampered lifestyle caused
style, if they believe that it offers some chance of by their asthma, and begin to accept it as the
improving their asthma. Again, if they know or norm. In a few cases, they may also have forgot-
believe they can perform an action successfully ten what it feels like to be well. Therefore, it may
(the concept of self-efficacy), and if they expect be necessary, depending on the type of person,
the outcome to be positive and measurable in for the healthcare provider to prescribe strong
and aggressive treatment measures so that they • Reading very slowly

experience a marked improvement in health or in • Staring at a page but not moving their eyes
their feeling of well-being. The educator can be back and forth
an advocate for this approach. • Asking questions about clear statements in a
document
15.2.5 Low-Literacy Individuals Individuals with low literacy will have diffi-
culties understanding oral and written informa-
What is literacy? The United Nations Educational tion. They tend to:
Scientific and Cultural Organization (UNESCO)
defines literacy as the ability to identify, interpret, • Use non-standard and possibly sub-optimal
create, communicate, and compute, using printed thinking strategies
and written materials associated with varying • Have unusual (and sub-optimal) approaches to
contexts. A “literate” person should be able to problem-solving
understand what is said, read what is printed, and • Nod in agreement without understanding
act upon the information provided. Unfortunately, • Minimize the use of body language (for exam-
the reality today is that about one in five ple, they may not nod or shake their head to
Americans is considered functionally illiterate. indicate agreement or disagreement)
According to the National Center for Educational • Require more time to understand
Statistics (NCES), 21% of adults in the United • Be unable to name medications, explain pur-
States (about 43 million) fall into the illiterate/ pose or dosing
functionally illiterate category, a number that is • Have difficulty filling out forms correctly
composed of 35% white, 34% Hispanic, 23% • Make excuses to avoid reading such as “I for-
African American, and 8% “other” [41]. Low lit- got my glasses” or “I don’t have time to read
eracy does not necessarily mean low intelli- this”
gences, nor does it mean that the professional • Become confused and/uncomfortable when
should behave with any less respect. asked to read anything
Health literacy requires skills such as reading, • Easily get angry and become frustrated
writing, listening, speaking, numeracy, and criti-
cal analysis, as well as communication and inter- To deal successfully with a low-literacy adult,
action skills. Lack of health literacy increases first establish whether intelligence is within nor-
healthcare costs, morbidity, and mortality. It mal range, and inability to read is an isolated
costs the US economy between $106 billion to problem. If so, getting help to improve reading
$238 billion annually [42]. may be the most important contribution the edu-
Certain behavior patterns are associated with cator can make. If low literacy is part of other
persons of low literacy. These include: learning issues, then:
• Difficulty relating events in order of • Organize the material

occurrence • Focus on the most important message first
• The inability to present a coherent, sequential • Present other information in order of impor-
history tance to the person
• The appearance of being nervous or • Break information into small logical pieces
embarrassed • Avoid jargon and medical terminology
• A lack of confidence • Use words and numbers that the low-literate
• Thinking in circles adult understands
• Giving indirect or irrelevant answers to • Use pictures, preferably simple line drawings
questions • Use concrete (not abstract) and examples
• Making excuses to avoid reading or writing familiar to the person
• Keep sentences short 15.2.6 The Older Adult

• Teach in very small steps so that progress
made can be seen The effects of aging are complex, and the educa-
tor must understand the main physiological
The CDC has a list of plain language words to changes attendant to this stage of life. For exam-
aid communication with adults of low literacy ple, cartilage degenerates and vertebrae become
[43]. Yet another website, that of the United Health rigid and less flexible in the respiratory system,
Group, has a glossary titled Just Plain Clear that as does the thoracic wall. Muscle strength and
has English, Spanish, and Portuguese alternatives ciliary action decline. Aging also brings with it a
for over 20,000 medical and insurance terms [44]. potential for increased susceptibility to infection,
It is important to remember that culture affects a decreased response to infection, and greater
how people understand, communicate, and respond impairment of cell-mediated immunity. There is
to information. Immigrants, both first and second sometimes increased social isolation and a neces-
generation, may have different health beliefs [45]. sity to adjust to changes in the course of several
Do not assume that immigrants are illiterate concurrent diseases. The older adult tends to:
because they speak poor English. They may under-
stand you clearly, but may have difficulty speaking • Suffer from multiple chronic ailments
because English is not their first language, or • Take a variety of medications, both prescribed
because it is just one of many languages they speak and over-the-counter, including (on occasion)
(many immigrants are bilingual). Further, they may medications prescribed for a friend or relative
be unfamiliar with the medical context of the words • Not adhere to management plans due to con-
you have used. Or, you may be the problem, the fusion, financial considerations, or health
explanation you provided might have been confus- attitudes
ing! English is a complex language under the best • Under-report and under-treat symptoms
of circumstances, and slang and jargon can make it • Associate many symptoms with aging
even more so for many immigrants. In this case,
suggest they bring a friend who is fluent in English The older adult may forget to take a dose, take
and their language. Speaking slowly and loudly is an incorrect dose, or take it at the wrong time.
not a solution. They may fail to understand instructions and the
It is the asthma educator’s responsibility to: importance of taking medication. Hearing loss
due to aging makes it difficult to differentiate
• Determine the literacy level and general level between high-pitched language sounds such as
of understanding of each person, and whether the letters f, k, s, and sh. Because of failing eye-
they understand the specifics of what is being sight, they may continue to take medication long
said. past its expiry date, or they may decide not to
• Choose both the correct style of tone and take medication because of unpleasant side
communication. effects.
• Set a pace of conversation that the person can Many older adults ignore signs and symptoms
follow. because they believe that there is no palliative
• Provide sufficient time for questions and measure or cure. Their reduced activity level
translation when required. makes fewer demands on their ventilatory sys-
• Use visuals and demonstrations with empha- tem, so that they may not get noticeably short of
sis on the ‘teach back’ approach. This requires breath. Further, their reduced perception of
that the asthma educator ask questions, or symptoms may cause them to ignore any short-
request an explanation or demonstration of ness of breath. Many expect a certain amount of
what has just been said or taught. This can be infirmity as inevitable and have been led to
helpful in determining whether they really believe that aches, pains, and other discomforting
understand you. symptoms are the result of advanced years and,
therefore, to be expected and tolerated. If the Learning is not age-restricted, nor does it require
older adult is also a caregiver, the difficulties are a formal setting. However, the time required to
compounded, since the caregiver is less likely to learn is greater for the older adult than for the
find the energy required to care for themselves. young, and learning can be impaired by the many
Thus, some of the challenges to be faced when medications that older adults take daily. The edu-
dealing with the older adult will include: cator must adjust the teaching approach to over-
come the belief that the older adult cannot learn.
• The increased time required to learn, particu- In teaching the aged, remember that thinking
larly motor skills ability may be impaired due to cognitive changes
• Coping with sensory and perceptual or decreased oxygenation. Dehydration, anemia,
deficiencies malnutrition, hypoxemia, toxic accumulation
• Management of multiple chronic diseases from medication, or even electrolytic imbalance
• Reduced motivation to learn can all compromise cerebral functioning. Pain,
• Anxiety and distraction that reduce ability to discomfort, and or fear may be barriers to
learn (such as health concerns about a learning.
partner) Issues of confidentiality arise with the older
• Increased caution adult just as they do with adolescents. Well-
meaning family members may wish to take con-
With the older adult, the asthma educator trol. However, the involvement of spouses or
should be sensitive to any barriers such as the partners and family members may be required in
psychological impact of retirement, bereave- some cases.
ment, loss of status, and imagined stigma of Some strategies for consideration are [48]:
being dependent on society and charity.
Retirement for some may mean the loss of iden- • Coordinated goal setting and shared decision-
tity as well as occupation. Older adults have to making, which involves the individual, spouse
accept increasing loss of independence, and pos- or companion, and members of the healthcare
sible reversal of roles when they become depen- team.
dent on their children, and loss of peers through • Development of a customized education
illness and death [46]. There will also be health program.
and financial hazards to be navigated. Insufficient • Selection an appropriate device (or devices)
food, either in terms of quantity or variety, lack of based on hand strength, coordination, sensory
warmth or increasing isolation, are critical status of fingers and hands, and cognitive
impediments to health and wellness [47]. Loss of function.
support systems is also a major cause for • Use of spacers and aids to MDIs and DPIs
concern. wherever possible, with frequent review of
Older adults will vary in their educational technique.
level and their reading ability. Many of them may • For adults with weak arms or hands, the possi-
have left school after their sixth grade and some ble use of Dycem or the use of foam to build up
have difficulty reading. Assessing their level of grip. (When applied to a device, Dycem makes
literacy is very important, particularly for those its surface tacky, and hence easy to grip.) This
older adult immigrants who may be able to speak may be supplemented, if necessary, by consul-
fluently but be unable to comprehend the written tation with an occupational therapist.
word. • Utilization of memory aids such as colored
Dealing with the older adult requires careful boxes, colored stickers, and other items with
teaching. One barrier that can occur both with the strong basic colors, since visual acuity
educator and with the older adult is the belief that decreases with age [49].
old people cannot learn and that they experience • Increasing illumination while minimizing
a decline in their mental abilities. This is a myth. glare, to help them see better.
• Speaking in a whisper rather than raising the • Rejection, due to lack of trust, a high level of
voice in order to help them hear. anxiety and worry, or being currently in the
• Use of large print when writing out their per- emotional stage of adaptation to the illness.
sonal action plans, and use of large-print edu- Fear and anxiety may also be expressed as
cational materials. anger and repudiation of any suggestions.
• Manipulation, which is based on anger and
As with people of different ages, a variety of claims that insufficient information is being
teaching tools should be available for use with provided by others, particularly by the health-
different types of learners. Cooperation should be care provider.
sought in integrating new required behaviors • Helplessness, or a feeling of being over-
with established behaviors to help them remem- whelmed due to a short attention span, limited
ber [50]. Considerations should also include pro- thinking ability and/or an impaired ability to
viding a learning situation where distractions and integrate information. This can also be the
competing stimuli are at a minimum. result of too many stressors resulting in an
When teaching the older adult, the asthma inability to cope or to focus (as in the case of a
educator must parent who has had to bring a child into
Emergency for a severe asthma attack). It may
• Provide motivation for learning also be due to over-saturation, where too much
• Assess their beliefs, present knowledge, and information has been provided, with insuffi-
learning style cient time to digest or study it.
• Build on existing knowledge • Ambivalence. Here there is understanding but
• Link all learning with past experience no commitment to action—sometimes the
• Ensure the information is relevant and essen- result of instruction. These individuals see the
tial for their asthma treatment need but do not realize the urgency for change,
• Minimize distractions during teaching particularly in environmental modifications.
• See that the teaching approach emphasizes a • Eagerness, with a desire to control the disease
single step at a time and achieve adherence.
• Monitor their energy level and attention spans • Acceptance, where the individual wants to
[51] cooperate and is resigned to doing whatever is
• Above all convey the belief that no one is too necessary to control the disease. These indi-
old to learn viduals are willing to listen, to learn, and to do
what is required to control the asthma.
One further suggestion would be to request that
they bring all medications, including non-asthma Depending on the many stressors to which
medications, to every clinic appointment. This they are subject, people may even fluctuate
request may be broadened to include anything they between these responses. There is no way to pre-
take to help their health. This may allow identifica- dict how they will react to education, for the edu-
tion of herbs that may help or harm them, and offer cator has no way of knowing the emotional
an opportunity to check for over-use or underuse; environment within which they are functioning.
to check the date of expiry; and to look for possi-
ble adverse interactions between asthma, non-
asthma, and OTC medications. 15.2.8 Cultural Competency
What is ‘cultural competence’ for the asthma

15.2.7 Response to Education educator? For healthcare professionals it is
defined as “the ability to effectively deliver
The individual’s response to education may be healthcare that meets the social, cultural, and lin-
one of the following [50]: guistic needs of their patients” or one that pro-
vides “culturally and linguistically appropriate In one study, non-white parents were found to
services.” This might sound like an innocuous believe that wheeze came from the throat and not
definition, but it is not. In fact, it is a potential from the chest [55]. In another study involving
minefield to be navigated with extreme care. For Caucasians and African-Americans, the latter felt
most healthcare professionals, cultural compe- that wheeze occurred in the upper airway, while
tency requires a major shift in thinking, in per- the Caucasians stated that it came from the lower
spective, and in attitude. airway [56]. Another study [57] found that par-
These are the facts: ents tend to be confused about the area within the
respiratory system from which the different
• Non-white Americans receive less care and a sounds emanate.
lower quality of care than do white Americans, With the rise in awareness of racism and dis-
for many reasons. crimination, there is increasing interest in recog-
• For those minorities who are foreign born who nizing inherent bias in all areas, including
often “do not speak, read, or write English,” healthcare. Cultural competence is one approach
language is a major barrier [52]. to this problem. Culture can influence individu-
• Even for those who are native English als’ values, beliefs, preferences, and health-
speakers: related practices. It is most evident when that
–– The words used to describe symptoms to person is in a minority, has low literacy, low edu-
healthcare professionals vary enormously cation, poor assertiveness skills, an inadequate
by culture and language of origin. level of English, and cultural beliefs about physi-
–– Healthcare professionals are often remiss cians and their role [58, 59]. These are significant
in using technical language rather than obstacles to overcome.
“street” language in talking to patients. Cultural competency is a process that requires
[60–62]:
Non-whites and whites describe asthma symp-
toms differently. Yoos and others [53] saw a differ- • Cultural awareness of one’s own culture and
ence between African-American and Caucasian how it has influenced one’s perspectives and
families in the way words were used and symptoms biases
reported. African-American parents were far more • Cultural knowledge of other cultures’ prac-
likely to use non-standard descriptions of symptoms tices and health beliefs – their traditions, fam-
to describe asthma attacks. Their children were also ily and social roles, etc. [45]
more likely than Caucasians to report more non- • Cultural skill and sensitivity to be able to col-
pulmonary symptoms, and to report cough as a lect the necessary medical information with-
symptom. Their parents were twice as likely as out causing offense or discomfort
Caucasian parents to report nocturnal symptoms and • Cultural curiousness—an intense desire and
chest tightness as a particular symptom. motivation to learn about other cultures with
The language of asthma differs not only acceptance, without judgment, and with an
between African-Americans and Caucasians but open mind
also between and within other ethnic groups. To • Cultural humility—a recognition that you do
give just one example: many languages do not not know enough which requires a continuous
have a word for “wheeze.” Hence, if a non-white life-long self-criticism and self-evaluation
person does not mention wheeze, or does not
understand the word when it is spoken by a Dealing with individuals of different cul-
healthcare professional, miscommunication will tures with different expectations is inherently
occur and asthma may not be diagnosed. challenging, particularly when care is “patient-
Misinterpretation is increased if English is the centered.” It requires getting to know the per-
person’s second language and if the person is on son and their culture, and then building a
Medicaid [54]. foundation of trust and respect. Showing a
genuine interest in the person’s culture and In addition, some strategies that will help
“home country,” and admitting that you (the communication no matter the ethnic, linguistic,
asthma educator) know very little or nothing or cultural background of the professional and
about it, is a good step to building trust. It is the person who might have asthma are to ensure
also a good way of obtaining valuable back- preliminary questions are very general. For
ground information without specifically asking example, instead of asking about wheezing, a
for it—often they will end up telling you about simple question to ask is about noise when
themselves. breathing. If there is a positive answer, then ques-
Strategies for dealing with different ethnic tions can get more specific, with, perhaps, the
individuals require: educator imitating a wheeze. In terms of “where”
the problem is they can be asked to place their
• Communication techniques specific to the hand on the part of the body they think is most
individual affected.
• Good listening and observational skills In summary, it is essential to remember that
• Being attentive to language barriers (and pro- every encounter is a cultural encounter, and that
viding interpreters if necessary) cultural sensitivity is the key to cultural compe-
• Using simple language tence. Every word, every gesture is laden with
• Avoiding medical terminology significance.
• Being receptive to discussions on alternative
medicine use
• Allowing more time for explanations 15.2.9 Mobile Applications
• More sessions for Asthma
• Hands-on activities, videos, and storytelling.
Recent years have seen a proliferation of
It has been shown that culture-specific pro- smartphone- based digital health technology
grams for minority groups improved quality of applications, or apps. These come in different
life for adults and children and reduced severe formats. The interactive variety collects personal
exacerbations that would otherwise have required data and then sends it to a healthcare provider,
hospitalization for children [63]. allowing the user to both receive and send infor-
The ETHNIC approach is suggested for use mation. The “standalone” versions only collect
with minority individuals. It has six parts: data, or allow individuals with asthma to person-
ally record their readings without the ability to
• Explanation—obtaining the individual’s send it. Apps involved in the health of the indi-
explanation of the disease vidual are in the so-called mHealth category,
• Treatment—discussing current illness and indicating that they are used with specific disor-
prevention ders such as asthma, food allergies, or diabetes.
• Healers—asking whether advice has been Currently there are over 1500 apps for asthma
sought from healers alone.
• Negotiation—of mutually acceptable options Asthma devices such as the AirDuo digihaler
• Intervention—that incorporates alternate and ArmonAir Digihaler work with apps that
treatments track use, peak flow rates, inspiratory flow rates,
• Collaboration—with family, healers and com- etc., and stores the data for review and/or trans-
munity resources mission to the healthcare provider.
Some apps are free, while others, such as the
The first three steps include information that is interactive ones, are purchased or rented by clin-
provided by the individual; the last three define ics that make them available at no charge to peo-
the collaborative approach between the individ- ple who use their services. mHealth asthma app
ual and the healthcare team. functions can broadly be divided into seven cate-
gories: “inform, instruct, record, display, guide, their asthma. Apps can increase knowledge and
remind/alert, and communicate” [64]. improve self-management [67]. When it comes to
Currently, apps are available for [65]: help with adherence, apps tend to use behavioral
strategies employing alerts, reminders, and logs
• Teaching [68]. Past systematic reviews found that the apps
• Training did improve asthma control and lung function as
• Tracking and visualizing health information well as quality of life but did not impact medica-
• Medication use tion adherence or costs, or show clinical effective-
• Treatment ness [64, 69]. A more recent systematic review
• Air quality information looked only at medication adherence for a number
• Social forums of chronic diseases (including asthma) and found
• Alternate treatments that apps do increase adherence and are effective
• Parent-directed use for managing medication at home [70]. However,
• Child-directed use the authors included a caveat suggesting that lon-
• Food additives ger studies, possibly of 12–18 months, are needed
to verify current conclusions.
There are also apps targeted to children with Mobile asthma apps have helped adolescents
asthma. These seek to teach them about their trig- with persistent asthma. In a proof-of-concept
gers and about asthma, and typically include vid- study, 20 adolescents had their Asthma Action
eos, games, and quizzes. Plan (AAP) downloaded to a smartphone for
People with asthma generally require apps 8 weeks, and received daily reminders to record
that are free, easy to use, reliable, accurately peak flows or symptoms and other reminders to
monitor symptoms, provide instructions during take their medication [71]. The app provided
an attack, identify airborne triggers, and reduce immediate interactive feedback based on each
the number of visits to their healthcare provider individual’s AAP, together with education about
or clinic (telemedicine). triggers, the need for daily controller medications,
They should also look for features such as reli- and when to use a spacer. Data provided by par-
ability, ease of use, security, quality of information ticipants was automatically transmitted to a secure
and privacy, and for so-called “validated” apps. site for compilation. Progress was evaluated with
These are consistent with the guidelines and not a pre- and post-test using the ACT. Scores showed
only guarantee the quality of the clinical assess- significant improvement in asthma control, in pre-
ment and recommendations provided but also venting an asthma attack, and a 93% participant
assess outcome measures. Two corporate-owned satisfaction level with the app.
“validated apps” are available: the Asthma Control One hundred adults, average age 48.5 years
Test (ACT), by GlaxoSmithKline, and the Asthma and 80% women, with uncontrolled asthma were
Control Questionnaire (ACQ), owned by Quality enrolled in a study and divided into a control
of Life Technologies. A third validated mobile group and a group that was fitted with electronic
asthma app for adults, the Mobile Asthma Severity medication monitoring and provided with feed-
Test (MAST), has been created by Queensland back via a smartphone and with phone calls from
University of Technology in Australia. clinicians [72]. Both groups were prescribed ICS
Kagen and Garland [66] rated five mobile and SABA. The result was that the group that self-
asthma apps, three of which (Kagen Air, Propeller monitored via a digital platform together with cli-
Health and Hailie) are interactive, offered the nician feedback had high ICS adherence and
greatest number of features and scored well. Two reduced SABA use. The study lasted 14 weeks.
stand-alone apps, AsthmaMD and Asthma Cook and colleagues [73] tested an asthma
Storyline, had similar ratings. app with adults aged between 17 and 82 years
Interest in the use of apps is increasing because over 4 months. The ACT was used prior to, dur-
of their potential to help individuals self-manage ing, and after app use to measure the degree of
asthma control. The app helped ACT scores While interactive asthma apps have the poten-
improve, reduced the use of oral corticosteroids, tial to help individuals with asthma control their
and increased FEV1. High levels of satisfaction disease and avoid exacerbations, asthma educa-
were reported. tors should be aware that once the app’s novelty
In practice, initial use tended to be frequent, has worn off, its use may become negligible or
followed by a rapid reduction, possibly once the random, and they may even lie about taking their
novelty had worn off and the app was seen as a medication. Credibility can become an issue.
chore. In a year-long study by Morita and col- Apps will be used effectively only when individ-
leagues [74], 8 reminder e-mails were sent per uals are taught about them. The use of the app
adult per week. Despite this, usage dropped to must also be monitored, and consistent encour-
58% by week 45, whereas 68% of participants agement provided to maintain the use of the app.
had been using the app at the fourth week. They The GAPP survey showed that education
noted that older individuals (50 years and up) increased treatment adherence [79]. As in so
were the most conscientious, with the highest uti- many other aspects of medical care, individual
lization associated with frequent email reminders and personal interaction becomes the key to
and physician visits, and they felt that the app building a trust-based relationship. And it is here
helped in the management of their asthma. Older that the asthma educator excels, by providing the
adults needed to see the applicability of the app personal touch and the helping hand that an app
to their personal situation and required education can never offer.
to overcome their reluctance to use these apps
[75]. Unlike older adults, “tech-savvy” adoles-
cents have no problems using apps [76]. 15.3 Teaching Methods
In a separate study, Hui and colleagues [77]
offered a prototype app for asthma self-management The methods and techniques chosen by the
on social media. Eighty-seven individuals signed asthma educator will depend on a number of fac-
up, but only 15 actually used the app for 30 days. tors. These include the number of persons
This study concluded that professional support was involved (whether one individual, or an individ-
essential to encourage both adoption of an asthma ual with family, or a group) their ages, the size of
app and ongoing adherence. This was clearly the room, the purpose of the lesson, the material
shown in another study [78] involving 60 adults to be taught, and other factors. For ease of use,
with asthma, 30 in an ASTHMAXcel app group the variety of teaching methods, techniques and
and 30 in the human-education group. In compari- aids for individuals, small groups, and large
son with the app group, the human-education group groups have been summarized in Tables 15.1,
had higher improved scores. 15.2, and 15.3.
Table 15.1 Teaching methods

Individual Small group Large audience
Interpersonal Activities based on group interaction and group Lecture
One-to-one communication dynamics Larger group
One-to-one interaction Lecture presentation
Giving explanations Discussion Closed circuit video
Demonstrating skills Role-playing Television campaigns
Exploring concerns Practice session Radio broadcasts
Answering questions Seminar Radio/TV shows
Role modeling Conferences Billboards and road
Role modeling appropriate behavior Review of past experiences signs
Discussing pamphlets Video conferencing Symposium
Discussing exhibits Simulation Debate
Simulation Games
Project/assignment Projects
Table 15.2 Implementation methods

Individual Small group Large audience
Individual interaction Problem solving Audience response systems
Skill practice Projects Self-evaluation through computer programs and apps
Contracting for learning Case studies Phone-in situations
Scheduling for self-learning Task completion exercises Phone surveys
or monitoring Exhibits Internet surveys
Discussion with others who Models Summary of information by narrator or host of program
have the same problem Critical incident process Series of questions for self-evaluation of learning that
are presented at the end of the program
Table 15.3 Teaching aids this can be done without them being aware that
Small there is repetition. To cite an example, a particu-
Individual group Large audience lar individual wanted a definition for asthma con-
Pamphlets Projectors Audience trol. This was repeated time and again, in different
Books Films response system ways, but it was not until the fourth session when
Videos Videos Recordings
Slide presentation
they exclaimed: “Now I understand what you
Self-study materials Posters
Computer simulation Displays Films meant by control.” It had taken both time and
Phone apps Flip charts many restatements for them to truly understand
Two- and three- White the meaning of asthma control. They were able to
dimensional models boards
repeat the words, but understanding and compre-
Posters Handouts
Visual aids Resource hension did not occur till the fourth session.
table Individuals with asthma can be given assign-
Visual aids ments such as maintaining an asthma peak flow
and symptom diary for a specific period of time.
They can also learn by monitoring symptoms and
15.3.1 The Individual peak flows. During the subsequent visit, the edu-
cator and the individual can interpret and discuss
Because this is a one-on-one approach, methods the diary. This makes for a more personalized
chosen should involve two-way communication, approach. Many materials suitable for individual
with each person providing feedback to the other. teaching are available:
For example, the educator can provide instruc-
tion and demonstrate the medication device while • Printed books, pamphlets, miniposters, asthma
watching to see if the person understands what is diaries, and peak flow charts
being said. This can be confirmed by asking • Electronic (downloadable) materials
them, in turn, to demonstrate the use of the • Visual aids (either hand-held models, or dis-
device. Thus, they can practice a new skill. Such played on a computer monitor)
individual interaction allows them to make mis- • Videos and interactive computer programs
takes without fear of embarrassment caused by • Self-help books and self-study materials (for
the presence of others or family members. purchase)
Again, because individual teaching is done in
private, the educator can explore and answer any Some guidance may be needed to ensure that
concerns, and provide both motivation and reas- the material is both current and accurate, but
surance. Printed material, such as pamphlets, can there is no shortage of choice. For more informa-
be reviewed in detail and as often as needed for tion on resources available for the individual, see
them to understand. While they may appear to the appendices in Chap. 16.
understand what is being taught, it may take Teaching techniques should be based on the
many iterations before they truly understand. In development of a mutually respectful relation-
such cases, it is important to restate the issues in ship between the asthma educator and the indi-
a slightly different way each time, and helpful if vidual. Techniques are enhanced by good
communication skills on the part of the asthma the role of a guide. Other participants within the
educator and by the choice of methods used to group become a resource by providing different
reinforce the information being taught. interpretations, which the educator can then rein-
Individuals also learn from discussions and force or correct, as necessary. As the members of
encounters with others who have similar prob- the group listen to one another, ideas are rein-
lems. Hence, organizing small group meetings forced and validated so that acceptance becomes
can be extremely helpful since some member of easier.
the group will likely validate the information that Groups allow individuals to gather strength, to
the educator has provided. (See The Small Group increase understanding, and to gain comfort from
later in this chapter.) one another. Experiences can be shared and com-
Individual or one-on-one teaching is extremely mon social problems—such as coping with rela-
effective. Studies [80, 81] have found that indi- tives or school environments—explored.
vidualized education provided meaningful gains Participants can offer personal solutions and the
in quality of life as well as clinical measures. group can discuss other possibilities. Learning in
There were significant decreases in days missed a group tends to be more effective when done in
from school and work, as well as visits to ED and this manner because each member is exposed to a
in hospital admissions. variety of sources, opinions, and viewpoints, any
Teaching should not be restricted to just one or all of which can either be accepted or rejected
teacher or educator or method. The team approach depending on prior experiences. In addition, a
to teaching can be extremely effective, provided well-functioning small group allows for individ-
all members of the team present a consistent mes- ual participation and prevents participants from
sage with different viewpoints and different being overlooked. The group can also be used for
emphases. Exposure to different sources of infor- problem solving, or to discuss particular inci-
mation is helpful for those with asthma. dents or tasks. It may be assigned a project or
Computer-aided instruction and phone apps even individual projects, which have to be
have been shown to be effective [82]. Computers reported to all members. Modeling, case studies,
are more and consistent than humans can ever games, video conferencing, and seminars also
be. A study by Huss and others [83] compared become effective.
conventional instruction about dust mite avoid- Small-group leaders need to be aware of com-
ance with conventional instruction supple- mon potential difficulties and disruptors, namely,
mented by computer instruction. Both adherence the:
and the number of dust mite avoidance measures
employed increased in the second group. This is • Interrupter, who never seems to allow others
an example of a combination of methods being to finish talking
more effective than a single approach. • Dominator (more details below)
• Late questioner, who always seems to ask a
question on a topic after the group has moved
15.3.2 The Small Group on to a new topic
• Silent person, who cannot really be described
For purposes of asthma education, small groups as a participant, who never asks questions and
are typically those with fewer than 15 members, rarely responds even to direct questions, no
ideally between 8 and 12 to facilitate matter how gentle the approach
participation. • Eloquent body language objector, whose pos-
The dynamics that occur within a small group ture screams disagreement but who never
of people with similar concerns work to the ben- voices dissent
efit of each participant. The educator becomes a • Consistent disruptive late arriver
coach as well as a presenter of information; then • Consistent early leaver (who may also be the
by encouraging discussion, the educator takes on late arriver)
The participant who interrupts and expresses a always that the graphics should reinforce the
view on everything [84] poses major difficulties. message, and not just be used to impress view-
This person tends to dominate and eclipse mem- ers). Once a presentation has been prepared, it
bers who are quiet or more reserved. The educa- can be used as a template. New treatments or
tor then has to choose between whether to retain, changes in approach can be easily incorporated.
or relinquish the role of mentor. If the latter is It is easy to customize the basic presentation for
chosen, the group then ceases to function as it different audiences and hence project an image of
should and can deteriorate into being nothing being up-to-date and respectful of individual
more than a sounding board for the dominant par- audiences.
ticipant. One way to prevent one person from When projection equipment for a computer-
monopolizing the agenda is to “go around the based presentation is not available, handouts are
group”—to draw out each member in turn so that easy to prepare.
everyone gets a chance to contribute and each In summary, small groups work best when the
member feels valued. educator is prepared, problems are anticipated,
Just as difficulties can be anticipated, so too and the material presented is suitable in both con-
can they be prevented. It is the duty of the educa- tent and style of presentation.
tor, as group leader, to articulate the rules clearly.
The rules need not be imposed by the educator,
but can be developed by the group under the edu- 15.3.3 The Large Group
cator’s guidance. They should include items such
as mutual respect, avoidance of interruption, and Large groups require a different approach. Two-
so on. way communication is limited, and the educator
Visual aids such as overhead projectors, films, becomes a lecturer, or a presenter. The educator
videos, computer-based presentations, flip charts, must then provide repetition rather than waiting
displays, handouts, etc. (see Table 15.3) can also for the audience to do so. The classical rule for
be very useful when used for small groups. The repetition at such presentations is: “Tell them
choice of medium depends on the message to be what you’re going to tell them. Then, tell them.
conveyed, and whether the presentation is formal Then, tell them what you just told them.”
or informal. Obviously, the words used to repeat the message
The medium of delivery should facilitate, but three times should be slightly different each time,
never dominate, the information. Participants and this in turn means that the educator has to
should not be impressed by the format of the pre- prepare the talk carefully and take the time to
sentation to the extent that it distracts them from understand the audience’s needs.
the content. A case in point would be the pre- Appearances on radio or television broadcasts
senter who uses a computer-based presentation should only be undertaken by the educator who
with many different types of slide “transitions” has received formal media training, and who
when changing from one slide to the next or one knows the needs of public media. Concise pre-
that uses different fonts and backgrounds. In such sentations given in a relaxed manner require
cases, the audience will often pay more attention training and practice. So does the crafting of
to the special effects in these transitions or to the “sound bites”—short, descriptive sentences that
backgrounds than to the contents of the slides. To the audience will remember.
avoid problems of this type, a simple format is Long-winded presentations will generally be
suggested. The medium is not the message. edited by the television station, with possibly
Rather, the medium should both convey and unsatisfactory end results. Unsatisfactory presen-
enhance the message. tations will also ensure that the educator never
PowerPoint and similar products can be receives a second invitation. Televised panel dis-
extremely useful. A presentation can be prepared cussions are useful in presenting many view-
with compelling graphics (keeping in mind points. There are a number of health shows on
television that provide this kind of discussion, information and allow participants to evaluate
using a variety of sources. Almost every local themselves. For instance, the presenter may for-
television station broadcasts some sort of health- mulate a number of questions at the end of the
related program. program and also provide the answers so that the
Presentations can be supplemented with hand- viewers can check their understanding of what
outs, posters, other visual aids, and displays. was presented.
Overhead projections systems, whether slide- or While this is the weakest model of education,
computer-based, can be used alone or in conjunc- nonetheless it goes out to a large audience. Thus,
tion with films and videos. Whiteboards and flip it can be cost-effective when a message must be
charts can also be used to teach. conveyed to a particular age group or disease-
For large-group presentations, the computer- specific group of people.
based slide presentation has become the norm.
Audiotapes, video recordings, and films are also
suitable. All these require the services of other 15.4 The Process of Education
professionals, such as graphics designers, so that
they do not appear amateurish. The presenter Teaching approaches for different age groups
should rehearse the presentation so that the final have been discussed, as have the methods, tech-
presentation is smooth, seamless, and entirely niques, and aids that are available to the educator
professional in every respect. This demands a when teaching individuals, small groups, and
considerable amount of practice and intense large groups. Consider now the process of educa-
effort. tion and how to teach the learner/person with
Techniques used with a large group must be of asthma.
the sort that invites the audience to participate. From the educator’s point of view, it is crucial
One electronic tool that can be used is the to differentiate between information, instruction,
Audience Response System (ARS) in which each and education.
participant is provided with a keypad with num- Information is unidimensional. Facts flow
bered buttons. Participants are asked to press a from a source to a recipient. The process does not
button in response to choices shown on a screen. demand the recipient’s attention or participation.
A central computer tabulates the responses and It does not require understanding or memoriza-
displays these either as a graph or as numeric val- tion. It is simply a presentation of facts. The
ues. For instance, it may indicate that “35 people learner may or may not pay attention. The learner
chose answer number one, 47 chose answer num- is not involved.
ber two, . . ..” and so on. The ARS is an extremely Instruction merely provides directions or
effective method to obtain feedback and involve guidelines. An example would be telling a person
members of the audience. what medication regimen should be followed. It
When it is impractical for the educator to is more individualized than information but it too
gauge the individual effect of a presentation that does not require any feedback from the learner. It
is aired to a large audience, then self-evaluation is is not designed to change behavior.
necessary. The process of self-evaluation can be Education is different. Unlike information and
undertaken in many ways. One common approach instruction, which are one-way flows, education
is to request would-be participants to phone a involves participation and interaction between
particular number or access a website and answer the teacher and the person being taught. The edu-
a series of questions. Because feedback is at best cator has to provide the learner with new skills
sporadic (in cases where callers are asked to together with the ability to put those skills to use.
phone in or access a website) and, at worst, non- When asthma education is provided, the educator
existent, the presenter is placed in a situation also has to motivate the individual to use the
where an instant response is not available. The knowledge for improved management of asthma.
best that can be done, then, is to summarize the The learner, on the other hand, must be willing to
learn and to participate in the process. Education,

therefore, is an intelligent and adaptive process,
which is slow, continuous, and time-consuming.
It cannot be hurried and it must be planned for.
In order to become an effective teacher, the
educator has first to consider, and then answer,
three basic questions:
1. How best can knowledge be transferred to the

learner?
2. How can the learner’s attitude be changed?
3. How can the learner be helped to apply the
newly learned knowledge?
Thus, learned behavior must involve all three

areas which have been defined as the cognitive,
Fig. 15.1 The domains of learning. (©The Asthma
affective, and psychomotor domains of learning. Education Clinic Ltd)
The domains are essentially the thinking-feeling-
doing areas of learning. Behavioral learning the-
ories explained how to modify behavior in the
process of fostering learning. The next section all three domains if long-term learning is to take
deals with learning from the learner’s point of place, and if skills are to be acquired.
view. This is essential if the educator is to target
those areas that will influence learning.
15.4.1 The Cognitive Domain
The cognitive domain deals with the intellectual

Points to Ponder skills of the learner. Cognition is a mental pro-
The educational process involves the cog- cess that has been described as the experience of
nitive, affective, and psychomotor domains knowing, as differentiated from feeling or acting.
of learning. The cognitive domain consists of six increasingly
complex levels, those of knowledge, comprehen-
sion, application, analysis, synthesis, and evalua-
tion. The process is based on judgment, and the
The domains are the levels of intellectual first stage is the acquisition of knowledge.
behavior that are important in learning. See To understand an example of the six steps
Fig. 15.1. They interact with each other and influ- within the cognitive domain, consider how most
ence the outcome of learning [37, 50, 85, 86]. people acquire asthma information.
Within each domain, there are a series of levels
and the learner can only proceed to the next level • After they acquire basic knowledge, they
after completing the current one. In Fig. 15.1, the should be able to state that asthma is a disease
levels become increasingly difficult as one proof the airways where triggers cause inflamma-
ceeds downwards. The time needed to complete tion, excess mucus production, and airway
each level will vary from individual to individual, spasm.
and every level has to be experienced. It is not • At the comprehension stage, they should be
possible to skip a level. Further, each domain able to identify triggers of asthma and list
influences the others, and they cannot be regarded common ones such as pollens, pets, dust, and
as distinct entities. The educator then must target mold.
• At the application stage, they can identify per- proceed from knowledge to evaluation depending
sonal triggers. on his or her abilities, motivation, and learning
• Analysis occurs when, after a lifestyle review, style.
they can list personal exposure to triggers. Learning may therefore be broadly defined as
• Synthesis ensues when they can explain how the process of taking in and remembering new
to avoid triggers. information, and then using that information as a
• Finally, after they understand how trigger guide to future action. In effect, the cognitive
avoidance leads to better control, they reach domain also includes recall. The taking-in of
the final stage of evaluation. information requires that it be analyzed and
understood. Analysis occurs when the person
Note that the language used above is “active,” accepts the information provided and starts pro-
indicating things that must be done. The verbs cessing it. Analysis requires perception, recogni-
define specific actions—list, identify, explain, tion, interpretation, and comprehension.
tell, and state. The educator must avoid the use of Interpretation is done in accordance with past
vague terms such as understands, knows, indi- experience and previous knowledge; and under-
cates, realizes, etc. These definitive actions are standing takes place in accordance with the per-
the only way the educator can judge whether the son’s knowledge set. Both require a context of
information given to the individual has been pro- previous experience.
cessed through the increasingly complex levels To ease assimilation, new information must
of the cognitive domain where each succeeding preferably be associated with what is already
level is built on the previous level. known. For example, the concept of airway
The cognitive approach to the usage of medi- inflammation caused by a trigger is easier to
cations should follow a similar path. In the exam- understand when compared to nasal congestion
ple below, italics are used to highlight the actions caused by a cold. The individual compares or
a person with asthma should be able to perform: relates the new information with previous knowl-
Knowledge defines asthma and the types edge about similar occurrences in order to better
of medications used in its assimilate it. Further, some form of contextual
treatment meaning has to be provided for the purpose of
Comprehension explains the purpose of the interpretation. If the association between new
different medications and old cannot be made, learning becomes diffi-
Application identifies medications accord- cult and the educator must take a new approach.
ing to their purpose Hence the understanding of the individual is criti-
Analysis tells how and when to use the cal to the teaching process.
different medications
Synthesis explains how medications are
used, and how to minimize 15.4.2 The Affective Domain
their side effects
Evaluation relates the fact that symptoms This domain deals with the emotional responses,
had escalated (recently) and values, attitudes, and beliefs that the person
that controller medication holds. It corresponds to attitudinal characteristics
was increased according to and involves reactions to others. Attitude is
the asthma plan defined as the inclination to respond, favorably or
The degree of difficulty increases with each unfavorably, to a concept, idea, object, situation,
level in the cognitive domain. Time is required to or person. It encapsulates behaviors that correlate
progress from the initial “knowledge” level with awareness, attention, interest, concern,
through each of the levels to the final “evalua- responsibility, listening, and the appropriate
tion” level, and the steps cannot be hurried. Each response to others, judged by internal mores.
individual requires a different amount of time to Culture plays a dominant role in this domain.
The sequence begins with reception and pro- has been taught unconditionally, or may accept it
ceeds step by step, through response, valuation, with reservations. In either case the information
and organization to the final level of characteriza- is accepted and placed in memory.
tion. As with the cognitive domain, the individual Information does not have to be completely
has to proceed through each of these steps, may understood in order to be assimilated.
not skip any step, and each step is more complex Assimilation may occur because of indirect vali-
than the previous one. dation or authentication—as, for example, when
The affective domain has been called the feel- the information is generally accepted by peers or
ing domain. It includes the degree of importance coworkers. This is often seen with those who are
and value placed on the information received, prescribed corticosteroids. Despite being
and the innate response to that information. The informed of the difference between anabolic ste-
source of the information directly affects the roids and corticosteroids, some individuals may
value placed on it by the individual. The more remain reluctant to take the prescribed medica-
trusted the source, the greater the value, and the tion because they are under the impression that,
more likely it is to be accepted. It also generates for example, “steroids will cause hair to grow on
the response to the information, again based on the chest”—a clear example of misinformation.
the perceived value. It organizes the information Yet, should another person inform them that cor-
or puts it into a framework based on past ticosteroids helped control their asthma, this vali-
experiences. dation from a different and reliable source may
Further, it categorizes the information against be sufficient for them to start taking the medica-
a vast body of already acquired knowledge— tion. Hearing information from more than one
against needs, fears, past experiences, culture, reliable source can be helpful to the process of
etc. For instance, a person who has had previous assimilation.
problems with healthcare providers may receive Many factors influence the affective domain.
new health information with skepticism (recep- The must want to learn and must be in the right
tion). Then, if the information does not address frame of mind before teaching can take place.
their particular concerns, it may be considered There are many barriers to learning (see Chap.
worthless (valuation) and discarded (organiza- 14). Personal problems—whether financial, emo-
tion). Their overt behavior may be polite accep- tional, or family related—can and will distract
tance (external response) even while internally a and hamper the ability to accept input. An unsuit-
decision has been made not to use the informa- able environment will also act as a hindrance to
tion (characterization). learning.
For this reason, information that is proffered The affective domain can be an aid or impedi-
quickly and hurriedly may cause them to assume ment to a learner’s ability to function within the
that the provider is in too much of a hurry to lis- other domains. Their attitude will determine
ten (valuation) and, as a result, to ignore poten- whether or not they are receptive to taking in
tially valuable advice. No matter how rushed or knowledge with the aim of putting it to good use.
pressed for time the educator is, the individual The affective domain is influenced by race, eth-
with asthma must feel that the educator’s entire nicity, social positioning, culture, and religion.
attention and focus is on them and their prob- Hence it is imperative that any assessment of an
lems. Attentive listening, and comments that are individual include attitudes, beliefs, concerns,
specific to their concerns, is the best way to fears, religion, culture, and country of origin.
ensure that the information given receives a posi-
tive reception—that the valuation is positive. 15.4.2.1 T he Affective Domain
Once the information has been accepted, pro- and Chronic Illness
cessed, and understood, listeners will challenge When a person falls ill, they go through stages
it. They will need to validate, justify, or authenti- before they adapt to the illness. Suchman [87]
cate it. After this analysis, they may accept what defined them as the symptom experience,
assumption of the sick role, contact with the asthma episode and may expect the person to
medical system, and the role of a person with recover quickly [88]. Sometimes healthcare
asthma. In effect, the person becomes aware of professionals and families share the myth that
symptoms and realizes that something is wrong, disappearance of wheeze is the same as
then acts sick, then has this illness recognized recovery.
and authenticated by the medical profession, and Lack of coping skills or a supportive frame-
finally moves through recovery and rehabilita- work can result in paralysis in decision-making,
tion prior to resuming a role in society. It is in inability to retain information or to function nor-
this last phase that they are eager and willing to mally [89]. Further, the same factors can cause
learn how to speed recovery and how to avoid a the perception of the disease to become unrealis-
recurrence of illness. As health increases, so tic and behavior to become self-limiting. This can
does the ability to learn and concentrate. The lead to further and more intense problems, more
sicker the person, the less inclination there is for exacerbations, and self-defeating and potentially
learning. dangerous behavior. Each hospitalization or cri-
For the individual with a chronic disease, the sis is seen as a major loss of normalcy, of health,
affective domain is of particular significance. of status, of normal function that is disruptive to
There is no termination of the sick role but an the family and the community.
alternation between periods of well-being and ill- Before any teaching can take place, the edu-
ness. Because there is no resolution, there is no cator must understand the individual’s position
complete recovery and they soon become aware in the cycle of grief, and the sense of loss caused
of this. Chronic illness is difficult to accept. Thus, by each attack. However, each time the person
part of any assessment must detail their: and the family use and adapt their coping skills
within a supportive framework, they grow stron-
• Current emotional stage with respect to ger. The resolution of every crisis helps them
asthma maintain a realistic perception of the current
• Ability to cope state of the disease. They control those aspects
• Level of support of reality that they are able to confront and deal
• Attitude with [90].
• Perception of asthma Attitude is of primary importance for the pur-
pose of both coping and teaching, and particu-
Chronic disease sets up a cycle where attacks larly so for chronically ill individuals. When
may increase a person’s sense of helplessness attitudes or beliefs are challenged, they result in
and powerlessness. They may feel that no possi- a vacillation in attitude which creates stress, and
ble action can significantly affect the outcome of with it, pressure to change. Do they see each
the disease. With each new episode or crisis, attack as a threat, a challenge, or a loss? How
there is an increased sense of fatigue, loss of con- they respond depends to a great extent on the
trol, and depression. In some cases, these feelings support system and the individual’s personality.
may cause them to deteriorate into a state of If there are no resources to handle the episode, or
paralysis where decisions are put off or not made, if access to healthcare is limited, their fear
thereby increasing the degree of crisis. increases. Every crisis provides an opportunity
Every attack is a setback and is followed by for growth or for deterioration in functioning
an attempt to re-enter and re-integrate with the capacity.
social life of the family. Families as a whole Thus, planning in the affective domain must
may adapt faster to this than the member with be based on the individual and the family’s feel-
asthma, and the lack of synchronization between ing about asthma and their reactions to crisis.
them and the family’s adaptation to the illness Planning that does not take crisis into account
can be stressful. Families often do not under- fails to provide the essential support that they
stand the depth of fatigue that results from an expect.
15.4.3 The Psychomotor Domain The user then takes the peak flow meter home
and practices using the device.
This third domain deals with the individual’s The next step occurs when they learn to graph
ability to learn a skill, manual, or otherwise. The the best of three peak flow readings on a scale.
steps begin with perception and proceed through This is a complex response and a measure of self-
readiness, guided response, complex response, confidence and understanding of the usefulness
and adaptation and ends with origination. of a peak flow diary may have also been attained.
The skill to be learned may be a new skill or The educator can measure the skill level by
the extension and refinement of an old one. Skill reviewing the completed asthma diary.
is defined as any movement that is fairly complex The next level of adaptation is more complex.
and which requires a certain minimum amount of Here, while using the peak flow meter and the
practice before it can be executed or performed. peak flow diary, the user reports that peak flows
Skill comes from doing something. It can be a drop when exposure to a trigger occurs. In effect,
mental skill, such as mental arithmetic, or a phys- they are now interpreting the peak flow diary and
ical skill, such as using a peak flow meter. The associating symptoms with triggers. The basic
example below considers the use of the peak flow use of the peak flow diary may then be altered
meter and traces the corresponding accompany- from monitoring the asthma to determining or
ing steps in the psychomotor domain. confirming triggers.
The first step requires that the user see the The steps in the psychomotor domain are very
need for the skill and make the decision to acquire easily monitored because it is this domain that is
it. The educator explains the purpose of the peak involved in the development of a skill. To help
flow meter and then demonstrates the skill. review the steps, the verbs that indicate the indi-
Sensory awareness is increased as they watch the vidual’s progress in the development and perfor-
demonstration. Watching a demonstration is far mance of the skill are shown in italics:
more effective than handing them a pamphlet that Perception watches the demonstration
explains how to use a peak flow meter. (The pam- of the use of a peak flow
phlet may be used as reinforcement, for them to meter
take home and review the steps in using the peak Readiness expresses willingness to try
flow meter.) This is the level of perception. using the PFM
Guided response attempts to use the PFM
under supervision
Complex response uses the PFM and graphs
Points to Ponder the PFM readings in the
Skill asthma diary
The term “skill” represents any move- Adaptation interprets the peak flow
ment that is fairly complex and requires a diary to confirm triggers or
minimal amount of practice prior to to predict exacerbations
execution. Origination uses PFM readings to
increase medications in
accordance with the asthma
action plan
Having attained this level, which is the second Once knowledge is assimilated, users can and
stage, they are now ready and willing to try using will employ it in those circumstances where they
a peak flow meter. The third stage commences believe it will be useful or advantageous. They
where they actually attempt to use the peak flow will manipulate the information, using it as a
meter under the supervision and guidance of the basis for making decisions or solving problems.
educator who gently corrects any errors and They act by directly or indirectly applying the
ensures that the proper procedure is followed. knowledge they have gained. As the level of skill
increases, the application is done with the 15.5 Planning for Teaching

minimum expenditure of both time and energy.
However, prior to mastery, they must: Teaching is the process of sequencing and then
presenting those stimuli that are likely to result in
• Be motivated to improve a desired behavior followed by appropriate
• Receive feedback during training concerning actions or comments that reinforce that same
the adequacy of their performance behavior. The goal of teaching is not to merely
• Be rewarded during successive periods of provide knowledge but to help individuals with
practice asthma use that knowledge for growth in every
relevant aspect of their lives.
Feedback must be relevant and must rein- This section details the steps required to plan
force, for skills are sensitive to inhibitory influ- a successful teaching assignment.
ences. That is, positive reinforcement will make In teaching, goals can be defined as:
them eager to continue practicing the skill,
while negative or delayed reinforcement will • Increasing knowledge
prevent the development of the skill. Practice • Improving or adjusting attitudes
makes perfect only when reinforced either phys- • Developing and maintaining skills
ically or psychologically. More frequent rein- • Furthering perceptual ability
forcement results in greater facilitation of the
skill. Lack of appropriate reinforcement results Each of these is a separate field of activity or
in deterioration of attempts and an increase in domain. Each of the three domains has to be very
errors. carefully considered, both for assessment and for
Continuing with the example of the peak planning purposes. Whether planning for an
flow meter, its usage must be checked regularly informal face-to-face interaction or a formal pre-
to ensure that errors have not crept in and that sentation, the teaching process requires four dis-
the procedure is done correctly. Once the skill is tinct steps [2, 40, 47, 50, 91]:
learned, they will look for opportunities to use it
and will be ready to do so when needed. Guided 1. Assessment, which allows the individual’s

response gives way to a more complex response needs and current level of knowledge to be
and to adaptation. For instance, a person who determined
has an asthma action plan and is no longer hesi- 2. Planning, during which learning objectives

tant to assess symptoms and increase medica- are defined
tions may also, as part of their response to 3. Implementation, which determines the teach-
increased symptoms, include relaxation exer- ing methods and resources that will be used
cises, rest, and hydration with warm liquids. 4. Evaluation, which determines the success (or
While the latter are not part of the asthma plan, otherwise) or the teaching process, and of the
they indicate a more complex response, an adap- learning that was accomplished
tation of information received in order to make
the skill more applicable. This combination, put
into practice as needed, is the true skill in self- 15.5.1 Assessment
management because the user has now decided
to expand the written plan to encompass all This first step of the teaching process is assess-
the needs encountered at the moment of ment [12, 92, 93]. This is where the educator gets
exacerbation. to know the person and their needs. It describes
Action and application are the desired results the data the educator collects in order to under-
of learning. They are integral and indispensable stand them. The educator’s perceptions of the
components of the learning process. person and the resulting expectations are impor-
tant, because people respond to expectations. • The family structure

Hence, an unbiased, open, and sympathetic • Their religion and culture
approach is essential for assessment. The educa- • Their home and work environment
tor has to listen not only to what is said, but also • The level of available family support
to what is left unsaid; and must also be aware of • The family structure and its decision maker(s)
the nuances of conversation. For this reason, lis- • Level of literacy
tening is the most important requirement for a • Preferred method of learning
proper assessment. • Their readiness to learn
The educator must understand the person’s • The impact of asthma on the family
attitudes, beliefs, and concerns without allowing • Their coping behavior
personal attitudes and beliefs to prejudice the • Health beliefs that may affect their attitude
assessment process. • Religious beliefs that can affect adherence
Attitudes are derived from beliefs and are with the prescribed regimen
strongly influenced by the expectations of the • Cultural customs and beliefs that influence
family [2]. Beliefs formulate attitudes; in turn, their attitude
these influence intentions that must be present • Fears and concerns they and the family have
before a behavior can be performed. The indi- about asthma
vidual will evaluate any required behavior from a • The pattern of asthma, their specific triggers
personal perspective and then determine whether and medications
or not to perform it. In order to help the individ- • The initial goals that they and their family
ual to make that decision the educator must, would like to define and attain
through questioning, understand the process and
obtain the necessary information about their atti- The questions asked should be gentle and
tudes and beliefs. Questioning has to be sensi- open-ended, so that a clear picture of the individ-
tively done, with questions that require more than ual’s most pressing needs and concerns is
a “yes” or “no” answer. obtained. This information will not be presented
Good communication skills are vital for in any order or even volunteered if the appropriate
proper assessment. The educator must try to questions are not asked. Close observation of the
understand what the individual’s responses mean, dynamics between family members (if present)
and avoid guessing. Asking for clarification or can help the educator formulate further questions.
repeating pertinent points prevents misunder- Much of the information will be gathered during
standings and confusion. It can also help the edu- the initial contact and when discussing the history
cator to paraphrase what they have said, and then of the individual’s asthma. The asthma educator
ask if it has been understood correctly. has to collect, sort, and categorize this data and
Assessment, then, is the first step in lesson then proceed to the next step, which is planning.
planning, for it determines the individual’s needs.
It should be used to obtain information on the fol-
lowing areas: Points to Ponder
The good educator constantly evaluates the
• The knowledge and/or misconceptions the methods, materials, and resources avail-
person and their family may have about able, as well as their own teaching style and
asthma performance.
• Their attitude towards asthma
• Past experiences that affect their interaction
with healthcare professionals
• Realistic understanding of the severity of the The information collected during the assess-
asthma ment process should be used to determine the
• Present expectations individual’s needs, prevailing attitudes, skills
required to perform the indicated healthcare Objectives must be defined in measurable,

behaviors, and the barriers to both learning and to “action” words such as:
performance, including those psychosocial fac-
tors that will influence the individual, including • List (as in “list the steps for handling EIA or
self-esteem, perceived autonomy, social adapt- triggers”)
ability, and family screening [12, 94, 95]. Family • Name (as in “name the two types of medica-
harmony, interaction, emotive communication, tions used in asthma”)
functional interaction, level of support, responsi- • Demonstrate (as in “show” or “demonstrate”
bility, supervision, and participation in carrying the use of the peak flow meter or how to use an
out an illness regimen also need to be determined. asthma medication delivery device)
Any individuals found to be at high risk for non- • Identify (as in “identify” the triggers in both
adherence should be seen more frequently. the home and work environment)
Assessment enables [32]: • Explain (as in the “explain” the difference
between controllers and relievers or how to
• Appraisal of the individual’s abilities and use the peak flow diary)
needs
• Identification of learning and behavioral Each word describes a specific activity that
goals, outcomes, and teaching strategies can be perceived and evaluated. Indeterminate
• Preparation of a customized teaching plan words such as “appreciate, understand, realize”
should not be used because they are not well
When done properly, it results in the establish- suited to describing objectives. Rather, the words
ment of reasonable and mutually acceptable used should indicate what the individual is
goals that are the result of discussion, consulta- required to do in order that the educator may
tion, negotiation, and shared decision-making. measure and evaluate the teaching.
Once assessment is completed, the planning The three domains are closely connected and
stage follows. Planning should take place both generally merge into one another. Objectives tend
before and after the actual teaching. While it is to relate to more than one domain. For instance,
easy to see the need for planning before teaching, if the objective requires the individual to use a
the idea of planning after teaching is not as clear. peak flow meter, then actual use entails a level of
Yet it is essential for long-term success for it skill which lies within the psychomotor domain.
evaluates what has been done and why, what was Further, they should be able to both read and
accomplished, what went wrong. This ensures interpret the results, which requires the cognitive
that the next teaching session will be more pro- domain. Whatever influences them to continue to
ductive that the previous one. use a peak flow meter lies in the affective domain.
15.5.2 Planning 15.5.3 Planning for the Affective

Domain
Planning is the second step of the teaching plan.
What does an educator plan for? Planning should The objectives here concern the emotional reac-
cover the three domains—affective, cognitive, and tions of a person who either has asthma, or who
psychomotor. But planning begins with one or cares for a child with asthma. In each case, the
more goals in mind, which have to be clearly initial reaction of disbelief often changes to fear
defined. They must be achievable given the teach- and helplessness in the face of the variability and
ing that has to be done. The learning objectives in perceived unpredictability of asthma. Helping
each of the three domains must be clearly and them establish a level of control and aiding them
unambiguously stated, and written down as part of and their family in designing coping mechanisms
the teaching plan for the individual and family. are crucial and important steps that help reduce
the level of fear and establish a realistic view of alter behavior. This leads to the definition of the
asthma. As their confidence increases, the level learning objective in the cognitive domain. One
of fear of another exacerbation decreases. See further step takes the plan into the psychomotor
Fig. 15.2. domain. Here the educator determines those
Complications arise if cultural or religious skills that are required in order to use the infor-
strictures are ignored in the prescribed medica- mation provided in the cognitive domain. The
tion regimen. For instance, during the holy month three steps are required in order to produce the
of Ramadan, a Muslim (a follower of Islam) will objective defined in the affective domain.
not take any medication between sunup and sun-
down. Prescribing a medication three times a day,
for such a person at such a time, becomes an 15.5.4 Planning for the Cognitive
exercise in futility. Hence the asthma educator Domain
should keep such considerations in mind, discuss
the issues with the individual, and not make any The educator has to determine what to teach—
assumptions about their beliefs and their degree both the level of knowledge and topics required
of adherence to them. for the individual to both function in this domain
The asthma educator needs to understand all and to move successfully into the realm of the
factors that could influence the individual’s han- psychomotor domain. The acquisition of skills
dling of the disease. The affective domain is the should be related to the information provided to
emotional climate within which learning has to them. They should be told:
take place. Since most individual’s needs are
clearly defined in this domain, it is best to begin • Why the information is important
there. The affective domain is crucial, for it deter- • How it will personally help them
mines their attitude to asthma and signals the • How they can apply it
level of adherence that has occurred with the pre-
scribed medication regimen. Thus, the initial Only then will they internalize or assimilate it.
emphasis should center on their attitude to asthma For those recently diagnosed, initial informa-
and its effect on daily activities. The affective tion provided should include a description of
domain includes the values, needs and emotional what happens in the airways during an asthma
responses of them and their families. attack, and how these physiological changes
Once the learning objective has been defined result in their symptoms. A very basic under-
in the affective domain, it is but a short step to standing of asthma and individual triggers is
determine what knowledge is required in order to essential; once they have this understanding, they
can understand why specific medications have
been prescribed.
They must be given basic information to fur-
ther the interpretation of their symptoms and in
order to develop the skills required for guided
self-management.
15.5.5 Planning for the Psychomotor

Domain
This final portion of the plan provides details about

those activities that they should be able to perform.
Fig. 15.2 The relationship between fear and confidence This is where they apply and manipulate the
in the management of asthma. (©The Asthma Education knowledge and skills they have learned. Whatever
Clinic Ltd)
the skill to be taught (as in deciding the corrective occurred, together with the method that will be
medical action to take when peak flows are in the used to evaluate how well the individual’s goals
yellow zone or in the formulation of different have been met.
adaptive and coping mechanisms), the manner of While the planning for teaching has been doc-
its teaching has to be carefully planned for. umented, step by step, it is also important after
The psychomotor domain is related to daily the evaluation to document:
asthma management. Of the three domains, it is
the easiest to teach. Because it is skill-related, it • Whether the attempt to teach was successful
is also the simplest to measure and to evaluate. or not
The keeping of records and their purpose, such as • If unsuccessful, the reasons why
peak flow diaries, is part of the preventive aspect • All the efforts made at counselling the
required for self-management of asthma. individual
In this domain, teaching is often done through • Interventions used
demonstration by the educator, followed by a • Referrals made
demonstration by the individual being taught. It • Anything else of relevance
is also the easiest domain in which the latter can
assess progress and in which the educator can Documentation is particularly useful if more
provide reinforcement and encouragement. than one person is involved in the teaching pro-
cess. A written record enables other members of
the team to reinforce and to continue the work
15.5.6 Implementation begun. It is also the formal record of what was
actually done. Asthma educators should remem-
Accurate assessment and careful planning are ber that if it is not documented, then it was not
essential for proper implementation. Once the taught—a case of “what wasn’t documented
objectives are defined for each of the domains, wasn’t done.”
the educator has to select the educational inter- Evaluation should be ongoing and continuous.
ventions to be used for this particular individual, Regular review of progress allows the educator to
bearing in mind: provide reinforcement and any required assis-
tance. The asthma educator will not be the only
• Their level of literacy source of information for the person. An evalua-
• Physical barriers tion should be made at each meeting of their atti-
• Psychological difficulties [96] (See Barriers tude and level of adherence with the management
in Chap. 14) of the asthma. A successful lesson plan is one that
helps them change, modify, or initiate those
The lesson plan should list the aids and tech- behaviors that are necessary to achieve the
niques that will be used to achieve the defined defined needs and goals.
objectives. These should be selected based firstly This is depicted in Fig. 15.3. The first tier con-
on the learning style and age of the individual, tains the assessment together with the goals,
and secondly, to help achieve the level of skill while the second tier defines the functions of the
outlined in the objectives for each domain. This educator. The lowest tier lists the role of the per-
is where the educator matches the learning son with asthma.
method to the individual’s preference. The cycle begins with assessment, with par-
ticular reference to the three domains. A proper
assessment aids the planning, execution, and
15.5.7 Evaluation evaluation of teaching by the educator. This is
followed by a transfer of information from the
The final step of the plan specifies how the educa- educator to the individual with asthma. The infor-
tor will determine the amount of learning that has mation may be an attempt to provide an under-
Fig. 15.3 The teaching and learning process for asthma self-management. (©The Asthma Education Clinic Ltd)
standing of what happens during asthma, an There will be problem-solving approaches;

interpretation of what symptoms indicate, or attempts to seek information; attempts at diver-
what peak flows mean. Then the educator has to sionary activities, relaxation exercises; and
provide anticipatory guidance. attempts to express emotions and articulate con-
All the asthma guidelines [97–101] emphasize cerns, and so on. They may also include positive
environmental control and stress that the asthma thinking techniques, the use of humor, and defin-
information provided must include ways in which ing and working toward set goals. Whatever the
the environment can be modified and exposure to strategy, it must be one that decreases anxiety and
triggers controlled. It is not enough to provide a allows them and their family to cope with the
list of things to be done or avoided. Practical tips asthma.
and techniques for controlling the environment After all this is done, only then can the educa-
must be included—too often, individuals with tor determine whether the goal has been reached.
asthma are unaware of ways in which they can It generally takes time for this to occur. If prog-
help themselves in avoiding their triggers. ress can be seen in some areas, particularly those
Anticipatory guidance should also extend to of greatest concern, then they are likely to return
life situations such as going to school, to camp, for further education.
or to a party, visiting a friend or relative’s home Frequently, objectives will have to be revised
or taking a trip. Guidance of this type is useful in during the teaching process so that they accu-
helping them anticipate the problems and emo- rately reflect what the individual has defined as a
tional upheavals they are likely to experience. need. Further, help may be required to maintain
This is also an area of concern for them. the proficiency that has been achieved to date.
Information transfer is followed by the learn- Over time they forget what they have learned,
ing of a skill in one of the three categories of and the educator must review earlier teaching to
communication, prevention, and management keep it fresh and prevent it from getting distorted.
necessary for them to achieve control of the Time also changes the perception of asthma and
asthma. The educator has to ensure that these past information. Newly discovered sources of
necessary skills are learned. information can result in new forms of misinfor-
The educator is also required to provide coun- mation. The educator then has the responsibility
seling and support. This may require referral of of ensuring that the individual has the necessary
the individual to other community resources. The current information to deal with the asthma.
objective of counseling is to help maintain a real- Continuous review and reinforcement of skills
istic perception of asthma, use appropriates cop- acquired must also be provided.
ing mechanisms, and obtain whatever support is As the individual achieves one goal, others
needed. The coping mechanisms will vary widely. will be defined. As a result, the process of
assessment, planning, implementing, evaluat- asthma symptoms. In both plans the sequence
ing, and goal achieving becomes a continuous followed is that of:
loop, with each goal achieved being at a higher
level than the previous one. The end result • Assessment
should be a person who lives as normal a life as • Determination of the learning objectives for
possible, who uses the smallest dose of medica- each domain
tion needed to control the asthma, who knows • Selection (or development) of the method of
how to control and (where possible) avoid exac- intervention to be used
erbations, and who feels part of an asthma man- • The means of evaluation
agement team. This is the ideal of guided
self-management. Learning principles are also defined for each
domain.
When combined with pharmacological treat-
15.5.8 Sample Teaching Plans ment, behavioral techniques have a positive effect
on the health-related quality of life for individu-
When teaching, more than one element can and als with asthma [102]. The pharmacological
should be identified and the appropriate inter- approach affects the physical realm while the
ventions performed at all three levels. However, behavioral approach is beneficial to improve-
it is essential to first concentrate on what con- ments in the psychosocial sphere.
cerns the individual the most. This helps reduce Sample lesson plans are shown in Tables 15.4
their level of anxiety, thereby making learning and 15.5. The first involves a person who has
easier. Two sample lesson plans are provided been prescribed inhaled corticosteroids and is
below. The first deals with the fear of one who fearful of taking them. The second is for an indi-
has been prescribed inhaled corticosteroids. The vidual whose level of anxiety is increasing as
second plan is for a person reporting increased symptoms increase.
Table 15.4 Sample lesson plan number 1—for individual AZ prescribed inhaled corticosteroids
Learning Learning
domain Assessment objectives Intervention Evaluation Learning principles
Affective AZ does not AZ discusses Discuss difference AZ talks about Reduction of fear
want Rx for fears between anabolic and side effect and anxiety
steroids—fear corticosteroids
Cognitive Determine AZ describes Discuss the role of AZ asks Relevance.
knowledge of what happens to anti-inflammatories in questions about Information is
inflammation in the airways when asthma treatment and controller related to past
the bronchi asthma occurs time for effectiveness. medication experiences.
from asthma and can explain Compare inflammation Perception is
the role of in airways to a necessary for
controllers mosquito bite or burn learning.
on arm or to symptoms
from a cold
Psychomotor AZ has a AZ differentiates Show AZ pamphlet and AZ sees the Perception is
similar device between relievers sample devices. difference necessary for
for reliever or and controllers Demonstrate correct between colors learning.
needs a new and uses both use of device and Reinforcement.
device correctly demonstrates Active
correct use of participation
the device
Table 15.5 Sample lesson plan number 2—for BJ who has increased asthma symptoms
Learning Learning Learning
domain Assessment objectives Intervention Evaluation principles
Affective Increased symptoms BJ discusses Educator uses active BJ talks openly Reduction of
causing anxiety concerns listening and helps about things that anxiety
BJ list times and make asthma
events, which worse
worsen asthma
Cognitive Determine BJ describes Use video and/or BJ can identify Relevance.
knowledge of causes causes of pamphlet to explain triggers in the Perception is
of inflammation in inflammation triggers and how to environment necessary for
the bronchi from avoid them learning.
asthma
Psychomotor Does BJ recognize Identify ways Discuss workplace BJ lists various Relevance.
triggers of asthma? of avoiding and home and how triggers at home Active
triggers to minimize and at work and participation.
exposure to triggers how to avoid them Knowledge is
organized and
sequenced
The educator needs to be accessible and

15.6 The Role of the Educator accepting, to use the right approach, and set the
stage so that successful teaching can take place.
The healthcare provider and the person who However, the best techniques and approaches
actually has and lives with asthma have different are of no consequence if the educator cannot
perspectives on asthma. The former brings establish a personal relationship with the per-
knowledge, objectivity, and experience with son with asthma. Empathy and effective com-
many individuals with asthma, all of which are munication skills are the most important of all
directed towards helping the latter. Individuals the requirements for effective teaching. The
are concerned about symptoms and their signifi- educator must also be skilled at putting them at
cance, and how to alleviate them with a mini- their ease, at providing support and reassur-
mum of inconvenience. They may also be ance. Further the educator must be able to pro-
concerned about the accuracy of diagnosis, or vide instruction at the right time, in the right
have other priorities that they consider more way, in the right quantity and at the right pace.
important.
They usually prefer not to focus all their atten-
tion on illness and disease. This is both under- 15.6.1 Principles of Communication
standable and positive, in that such an outlook in a Consultation
sees life as being more than the limited view
imposed by a disease. Each educator will develop a unique style for
However, when asthma can have a major interacting with individuals with asthma and
impact on their quality of life and may, on rare their families. However, acting as a consultant
occasions, be fatal, they need to move beyond the may be an unfamiliar role. As an educator devel-
relief of obvious symptoms. They must be aware ops a teaching style, it is essential that they also
of the dangers inherent in asthma, and the educa- gain a knowledge of the principles of communi-
tor must teach them how to cope with asthma so cation underlying consultation.
that it does not control their life. The educator has A consultation with an educator is not the
a major role to play. same as a consultation with a healthcare provider,
but some of the principles are likely to be com- perfume—are known triggers of asthma.)
mon to both situations. The Calgary-Cambridge Personal appearance becomes pivotal in estab-
model described here was developed for student lishing the tone of the educator-person
physicians, but educators will find much of it relationship.
helpful [103] It is as follows: Another important element is the attitude and
expectations of the educator. It is important to be
1. Initiate the session: non-judgmental and open. People often make
• Establish initial rapport. seemingly illogical decisions, and reactions to
• Identify the reasons for the consultation. such decisions must be avoided. The educator
2. Gather information: must stay supportive, no matter what they do or
• Explore the problems. how great the level of frustration at their chosen
• Understand the person’s perspective. inappropriate behavior.
• Provide structure to the consultation. Posture is indicative of attitude. An educator
3. Build the relationship: who sits next to a person conveys an impression
• Develop rapport. of equality as opposed to dominance, which is
• Involve the person. conveyed by sitting on the other side of a table or
4. Explain and plan: desk. The educator may wish to lean toward
• Provide the correct amount and type of them, but not all the time, as this can convey a
information. threatening attitude. It is advisable to be friendly
• Aid accurate recall and understanding. and informal (if that is what the person prefers)
• Achieve a shared understanding; incorpo- and let the tone of voice and body language indi-
rating the person’s perspective. cate a willingness to help, and not judge. An open
• Plan; then make decisions together. unbiased atmosphere will make them willing to
• Consider options in explanation and talk as long as the educator is willing to listen!
planning: The general impression generated by the educa-
–– If discussing an opinion or the signifi- tor should suggest a relaxed, collaborative part-
cance of problems. nership between educator and the person with
–– If negotiating a mutual plan of action. asthma. Hence, the attitude of the educator is of
–– If discussing investigations and prime importance.
procedures. The basic principles of asthma education for
5. Close the session. the asthma educator are briefly summarized
below.
15.6.2 Setting the Climate Honesty If the answer to a question is not

for Teaching known, the educator should say so. People will
respect such an answer more than a best guess.
The educator sets the climate for teaching. Expressions such as “I’m not sure,” or “I don’t
Deportment, clothes, speaking styles, and envi- have the answer for that,” or even a straight “I
ronment—all of these help affect the “climate.” don’t know” will be appreciated. They do not
To begin, consider the educator’s physical expect any person to know everything.
appearance. Both bearing and dress will convey There is a strong belief in the “wounded
unspoken messages. For instance, an educator healer” and studies have shown that people
who wears scented products to a teaching ses- respond better to healthcare workers who have
sion gives the impression of not knowing, or, asthma [104], even though they were not told
even worse, not caring about the person’s asthma. about this in advance. They think that someone
(Scented products—such as deodorants, hand who has the same condition truly understands
and/or body lotions, hair gels, hair sprays, what they are going through. This is only partly
scented soaps, aftershave lotions and above all true, as each experience of illness is unique and
individual. The “wounded healer” must be care- communication is pre-judgment and assumptions
ful not to assume that the methods that have that have no basis in fact.
helped them will also help every person. At the
same time, an educator who does not have asthma Alternate sources It is unhealthy for individuals
should not pretend to have asthma. Initially those to develop a dependency solely on the educator.
with asthma may believe the educator, but when Alternate sources of information and support
they find out that this is not true, the lie will be should be made available to them. The team
seen as a betrayal, and they will not believe any- approach involving pharmacists, respiratory ther-
thing further that is said. Honesty is the best apists, healthcare providers, other health profes-
policy. sionals, and support groups as alternate sources
of information should be encouraged. A list of
Acceptance The educator will find it difficult to acceptable websites and apps can also be sug-
stand by and allow individuals to make decisions gested. (See Appendix 16.2 for recommended
that will cause them grief later. If they choose to websites.)
indulge in self-defeating behaviors (going into
smoke-filled bars, smoking tobacco products, Limitations The educator must be aware of
keeping pets that trigger their asthma), their deci- personal limitations. Personality differences or
sions have to be accepted with equanimity, in a the needs of a particular individual may hinder
non-judgmental manner. Options should be the educator’s attempt at teaching. Hence refer-
clearly explained together with the results of ral to others, such as a social worker, psychia-
each, but the final decision has to be left to the trist, psychologist, healthcare provider,
individual. specialist, or other resource, must be consid-
The educator must avoid interpreting experi- ered. There will even be times when personality
ences of individuals with asthma, particularly conflicts may make teaching not only difficult
when they relate negative experiences with but a waste of time. In such cases, a referral to
healthcare providers or healthcare professionals. another member of the asthma team will prove
Statements should always be accepted in a non- more productive. Referral should also be con-
committal tone of voice, and all comments sidered in those cultural cases where the indi-
avoided. The educator, like the healthcare pro- vidual may prefer to deal with a person of the
vider, should not expect perfect adherence. same gender.
Studies [105, 106] clearly indicate that some Parental counseling and specific psychologi-
form of non-adherence is the norm. Even an cal interventions are required (especially for chil-
extensive education program emphasizing self- dren) when there is evidence of:
management [107] did not improve adherence
levels (which typically hover around 40%). • Emotional or behavioral problems
People make mistakes in peak flow dairies and in • Family dysfunction
medication usage. Memory is uncertain and • School-based difficulties
hence the educator must accept what a person • Non-adherence with medication and treatment
with asthma chooses to do, say or record. plan including avoidance of triggers
• Failure of treatment [108]
Respect Age should not determine the attitude
of the educator to those with asthma. Whether The asthma educator who recognizes the
old, young, adolescent or child, all must be restrictions and boundaries of this profession
treated with respect. Assumptions on the basis of should not hesitate to involve other profession-
the way they dress, talk, walk, or behave should als who can help a particular individual. Part of
not be made. Unless there is understanding of the function of the asthma educator is to help
what motivates them, there cannot be any effec- families obtain the professional help they
tive communication. The greatest hindrance to require.
Relationship Education is based on trust. A rela- 15.6.3 Ways of Teaching That Can
tionship of mutual trust takes time to develop but Cause Problems
is vital for learning, since there can be no learn-
ing where there is no trust. A “soft” approach, as The very act of teaching can cause problems.
opposed to an authoritarian one, will help develop These include the educator’s lack of confidence
the view that the educator is a partner, a coach, in personal abilities (as well as the person’s lack
and a team player instead of one who instructs of confidence in the educator). The only way to
and dictates what should and should not be done. prevent this is for the educator to be well quali-
The educator’s attitude is the most critical ele- fied and up-to-date. Thus, the educator will speak
ment in the process of education, and the rela- with confidence and certainty, both of which will
tionship between educator and the individual be transmitted to those who seek help and
with asthma must be one of mutual trust and increase their confidence in the abilities of the
respect. educator.
Negative expectations on both sides will cre-
The educator needs both to provide emo- ate obstacles. Educators who do not expect much
tional support and to help the individual under- from individuals who come to them for education
stand the condition. Their anxiety should not be will only get what they expect. It is a remarkable
viewed solely as an outcome of the disease. fact that in teaching, the teacher’s expectations
Continued physical and medical problems may govern the student’s response. It is no different in
cause emotional distress in the chronically ill asthma education. If both participants have nega-
[109]. Any perception of indifference may cause tive expectations, then the teaching becomes a
them to feel deserted by a person whom they waste of time. If, however, the individual has a
expected would be supportive. By being aware negative outlook, then the educator can work to
of their needs, including emotional needs for change that.
reassurance and support, the educator can help A positive environment is an aid to teaching
them: and learning. This includes both the physical
environment and the emotional climate in which
• Avoid feelings of hopelessness and the teaching takes place. A poor instructional
powerlessness environment will make it difficult for the educa-
• Define and achieve goals tor to do a proper job of teaching and for the indi-
• Help prevent further deterioration vidual to do an appropriate job of learning. The
• Develop other social contacts environment can become a distraction for both.
• Maintain emotional stability Interruptions, noise, and lack of privacy all con-
• Cope tribute to a negative environment both for learn-
• Find a new meaning in life ing and for teaching. See Sect. 14.7 in Chap. 14.
If there is little or no reading material avail-
In summary, the educator’s attitude toward the able for the individual then more attention must
person with asthma sets the climate of learning. be paid to oral instruction. This too may have
Unspoken attitudes and assumptions can color negative effects. There is a saying which it is
the learning environment and, if negative, nullify most appropriate to repeat here:
all the efforts of the educator. Individuals are
influenced by the educator’s perception of them. • I hear and I forget.
Their readiness to learn is influenced by the edu- • I see and I remember.
cator’s perception of their ability to learn, as well • I do and I understand.
as their past experiences, motivation, current
health status, and ability to cope with health Written materials (“handouts”), whether paper
problems. or electronic, must be available for every possible
level of literacy, so that the individual never Too much information is not the same as
leaves empty-handed. Written material if read good education. Familiarity with the different
will reinforce what has been said, provide oppor- aspects of asthma makes the enthusiastic new
tunities to gather more information, and allow educator neglectful of the individual’s learning
them to review what was done and what is needs, forgetful of the requirement that learning
expected. What is said tends to be forgotten, but needs time, and oblivious to the fact that teach-
materials that are written or printed will act as a ing has to be paced. New educators make the
reminder. Problems can be caused by a lack of common mistake of providing too much infor-
direction in learning. Those learning about mation, and ignoring the needs and concerns of
asthma are astute, and will be aware of the times the individual. Their enthusiasm leads them to
that the educator has come unprepared; and when overwhelm the person with often-useless infor-
the order in which the information is provided mation. In a hurry to share their new knowledge,
lacks logic and is haphazard. Each teaching ses- they rush to fulfill what they assume are the
sion must have a goal. If there is no defined goal, needs of the individual. Hence, poorly defined
and if the educator does not know where the ses- needs give rise to wasted efforts and informa-
sion is heading, then neither will the individual. tion overload.
They are less likely to cooperate at such times, Inadequate communication skills, the use of
and more likely not to come back. obscure or unfamiliar medical terms, poor listen-
Communication skills are of primary impor- ing skills, hurried teaching because of time con-
tance. Language, social, and cultural gaps straints, and even lack of adaptability—all these
between the educator and the individual are all create barriers and problems within the teaching
barriers to communication, as are their receptive- process [94]. The educator who does not strive to
ness, understanding, and memory. balance needs with age-related learning tech-
A healthcare provider who does not empha- niques is doomed to fail, as is the educator who
size education will send a contradictory message fails to:
and confuse the individual with asthma.
Other limitations imposed by the educator • Reassure and address the concerns of those
include an inadequate assessment of the individ- who come to them for education
ual’s needs and readiness to learn. The educator • Encourage active participation
who bases teaching on personal preconceptions • Discuss the objectives of the teaching and
of what others need, instead of assessing and their relevance
identifying the actual learning needs, does a dis- • Ensure their attention
service to the person and wastes valuable time • Build on past experiences
[50, 85, 110]. Good teaching is based on the • Patiently repeat and reinforce what has been
assessment of individual needs, in relation to the taught
person’s unique situation, and responds to areas
of concern that the person believes to be critical. People—and not just people with asthma—
Analysis of demographics, personal variables, need time to learn. When they are denied the time
and characteristics including learner motivation to ponder and assimilate what has been taught,
and how the illness has affected the daily life of they will forget, and the educator’s efforts will
the person, together with an understanding of have been wasted. Proper pacing (the provision
them as an individual and not as just one more of the correct amount of information at the cor-
“client” is essential to good teaching [35]. rect speed), together with sufficient time to
Further, any attempt to use a single standard tech- reflect, is one of the hallmarks of good teaching.
nique for teaching negates the opportunity to use Time should be allowed for them to demonstrate
an individualized and innovative approach and is what they have learned and the skills they have
doomed to fail. achieved.
Lack of educational preparation and dearth of Listen

interdisciplinary cooperation are self-imposed The educator should always start by listening. It
limitations. So too is the inability to deal with age is through listening that a great deal can be
and developmental learning patterns, insufficient learned about each person—their knowledge of
knowledge of cultural and ethnic practices and an asthma, education, literacy level and ability to
inability to communicate effectively [93]. understand what will shortly be taught. Once an
appreciation of the person has been developed,
education—whether at the elementary or some
15.7 Teaching Strategies advanced level—can begin. Listening is the key
to understanding. Without understanding, there
This section presents teaching strategies and use- can be no teaching.
ful hints for the educator.
Motivate
Provide Information Motivation has four major components, all based
For those individuals who require only informa- on the person’s perception of susceptibility, ben-
tion, their best source—besides the preliminary efits, severity, and barriers [111]. Their assess-
information that the educator can provide—is ment of asthma may be markedly different from
any of the reputable state or national allergy/ that of the healthcare professional. They (as do
asthma organizations and their websites. A hand- all individuals) perform their own cost-benefit
out listing all such organizations and local sup- analyses, and will decide for themselves if a spe-
port groups in the city or region should be readily cific action provides a clear and distinct benefit.
available. The benefit may be a good night’s sleep or
A selection of information on asthma—bro- reduced hospital visits, but it must be clear and
chures, pamphlets, electronic handouts, lists of easily attainable. They make decisions based on
web sites—should also be available, and many their perceptions of what will work for them.
hard-copy pamphlets may be obtained at no Fear itself is not a motivator. High levels of
charge from pharmaceutical companies. While fear will result in denial, and they will often react
nearly all of them contain some advertising, they by ignoring the problem [112]. A small amount
also provide facts in a clear, easy-to-read format. of fear can help motivate them, while an interme-
Articles on asthma are also available, usually for diate level produces intermediate change.
a fee, from asthma/allergy organizations. In the Lack of motivation is an impediment to learn-
interests of further education, every individual ing [85]. This lack may be due to lack of appre-
should be given written material at the end of ciation of the severity of asthma or acceptance of
each visit. the diagnosis, or may result from denial of vul-
nerability. It may even be due to the lack of posi-
Match Information to Needs tive influences in the person’s life. Individuals,
An effective educator is one who is able to listen especially those who do not have severe asthma,
to, and then successfully talk with those who may not be motivated to learn the skills necessary
come to be educated. The secret to successful to control their asthma. Since their asthma poses
asthma education is to give them the information only a periodic problem, their approach may be
they need, at the level of detail with which they to deal with it when it occurs and not attempt to
are comfortable. In order to do this, the educator prevent an exacerbation. Whatever the reason,
must be able to listen intelligently and attentively the lack of motivation has to be dealt with and is
to them. A good initial assessment will help an essential part of teaching.
define the needs and permit the educator to pro- Motivation results from helping them define
vide that necessary information to the depth that their goals and determining the proper level of
they require. purpose. Goals must be realistic, well defined
and above all relevant. Motivation helps them success, and thence to produce satisfaction from
develop skills and sources of support, so that needs that have been met.
feelings of hopelessness can be avoided. Teaching
coping skills helps motivate them to prevent Use Few Technical Terms
those negative emotions that counter the positive When dealing with individuals with asthma there
effects of a therapeutic regimen and to adapt to will be many times when asthma concepts should
the changes concurrent with a chronic disease. be presented in a simplified manner so that the
Individuals with asthma require motivation in individual can understand them. Care should be
all three stages of behavioral change. These taken when using technical terms. Use language
include: that they will understand. Some will be comfort-
able with words such as inflammation or trachea,
• Commitment to change and feel insulted if talked down to, while others
• Initiating the behavioral change will be confused. Abbreviations should also be
• Maintaining the changed behavior [110] avoided. Many healthcare professionals make
extensive use of acronyms and abbreviations
They do need help in making the decision to (such as MDI, DPI and SOB, etc.). These often
change their behavior. All too often they do not lead to more confusion than the actual technical
know that education can help them manage and words.
control their asthma. Because there has been very Words such as bronchodilator, bronchi, alve-
little stress, at the public level, on educating those oli, triggers, and prophylactics are technically
with asthma in methods to achieve asthma con- correct; but most people do not understand them.
trol, few of them realize the benefits. Till the 1960s, the term “prophylactic” was used
Many individuals have had unhappy experi- in polite society to refer to birth control devices,
ences with educational programs that were essen- usually condoms. Older adults, hearing this word,
tially information-based (“information dumps”) may wonder whether such items will help their
and not conducive to behavioral change, and that asthma!
did not meet their needs. Early educational pro- In addition to the barrier of medical terminol-
grams often consisted of talks by a conglomera- ogy, the challenge of teaching individuals
tion of health professionals, who often lectured remains. The solution is to keep the language
as if the audiences were all healthcare profes- very simple. Instead of using words such as bron-
sionals. Unexplained technical terms were used, chodilator (and so on), the educator can talk
and the end result was that attendees (and some about relievers, controllers, airways, air sacs, and
health professionals, too) left with the belief that things that make asthma worse. Listeners will
asthma was a condition that was best left in the understand what is being talked about—and that
hands of specialists. Education programs have understanding is, at this stage of the teaching pro-
come a long way since then, but there is still cess, far more important than a minor technical
some resistance from those who unfortunately inaccuracy.
were exposed to those early “teaching” methods. Once the basic concepts have been communi-
Motivation can both help individual to make cated, the person can be provided with any fur-
the initial decision to change certain behaviors, ther details that are necessary. Each person will
and also help them begin that change. Motivation however have unique requirements, and will need
can help lapsed individuals to regain and information in differing degrees of detail. This
strengthen learned behaviors. Practice and acqui- does not mean that the correct terminology can-
sition of skills will also prevent or at least mini- not be used. Depending on the person, it might be
mize lapses. A strategy to motivate them should extremely helpful if the terms used were
therefore include attempts to arouse interest, to explained, and they were told about the medical
create relevance, to cultivate an expectancy of terms that healthcare providers use. This will
strengthen their self-confidence. More impor- Only as much information as required should
tantly, their ability to use the correct term will be provided, and to the level needed. Different
minimize the danger of miscommunication words and different approaches should be used
between them and their healthcare provider. while ensuring that they understand what has
been said. Information should be presented in
Choose Words with Care short, concise sentences. The sequence must be
The words used must be carefully chosen to suit logical and easily followed without digressions
the individual’s background, education, and com- that serve only to confuse. A good lesson plan,
prehension levels. Even the most innocent- prepared in advance, will attempt to convey one
sounding medical terms can easily, and idea at a time in a logical progression that builds
unintentionally, confuse people. It should never on past experiences, thus connecting the new
be assumed that they understand the terms in the learning with the old.
same manner as a health professional does. With any more than small quantities of infor-
In a test, subjects were asked to explain what mation, it is essential to give them time in which
they understood when they heard the term “early to digest the material provided. They need to be
warning sign.” Among the incorrect explanations able to link the information with what they
they provided were the following: already know. Only they can assess its
Early happens first thing in the morning usefulness.
Warning what you hope the policeman will give
you instead of a speeding ticket
Signs things beside the road that tell you Points to Ponder
where to go Principles of education
Trigger that part of the gun which makes it fire
The problem with jargon (and the phrase • Feedback
“early warning sign” is precisely that) is that jar- • Reinforcement
gon has a specific meaning to those people who • Individualization
are in a specific industry or field. Sometimes the • Facilitation
meaning is very local, such as within one unit in • Relevance
a hospital rather than the whole institution or a
whole profession. Outsiders, hearing what sounds
like everyday English, may come up with a com-
pletely different interpretation, as shown by the Manage the Learning
examples above. The asthma educator can help the individual with
It is very easy to slip into jargon. A good asthma manage the learning process by paying
asthma educator constantly monitors the use of particular attention to a number of points. These
words, and keeps language simple, and thereby include breaking down the task into a number of
continually improves their communications small steps with graduated levels of difficulty, so
skills. that they feel a measure of success with each
step.
Teach in Small Doses For instance, the educator may explain why an
Teaching should be done in small doses. Most asthma diary is used, and indicate that using a
people experience information overload within a peak flow meter properly is the first step in the
minute or two when faced with a long string of process of keeping a diary. Once they can use the
new facts or information. New information is meter correctly, they can be taught how to plot
best presented in small doses, with time for ques- the readings on a graph and then to interpret the
tions. The purpose of teaching is not to impress resulting chart. This may involve using other
individuals with how much the educator knows, sample charts. These can show very clearly that
but to answer their concerns and meet their needs. allergen exposure and a viral infection cause a
drop in peak flows. This graduated learning helps no one method or approach that can be used suc-
them see the goal and the steps toward the goal. cessfully with all individuals.
Persistence and frequency of teaching are
important in helping them remember the content Provide Other Resources
and purpose of what has been taught. Follow-up The individual must realize that the asthma edu-
provides reinforcement and is indicative of cator, the healthcare provider, the pharmacist,
expectations. and the family are all part of the same team, and
The educator should use the five principles of that each member is dedicated to working with
education—feedback, reinforcement, individual- them. For a young person, teachers and school
ization, facilitation, and relevance [113]. staff should also be considered as part of the
The use of similes (comparing the asthma team.
plan to driving and maintaining a car) can help Some individuals may need to be referred to a
the learner visualize information and see its rel- psychologist, social worker, community organi-
evance. The use of familiar contexts, elabora- zation, or support group for more help. A list of
tion, and the use of sufficient detail (so that they these resources should be readily available. A
understand) is extremely helpful particularly number of national and local support groups exist
since excessive detail will result in boredom. and the asthma educator should prepare a list of
Information should be placed in a personal con- organizations and support groups in the area and
text so that they understand why it is being make this information available to them.
taught.
The educator must spend as much time as is Use Effective Techniques
needed in order for the teaching to be successful. Once the educator has begun to understand the
Limitations imposed by time and the setting do individual, the teaching approach chosen can be
need to be considered but it is far better to focus adjusted. However, there are certain techniques
on teaching one item and to do it well than to try and factors that will help in the teaching of every
and cover many items (even if they are important) person. These include linking, the three Rs, and
in one session. The amount of time spent teach- the use of different media.
ing is directly related to the outcome.
Linking All learning is built on past experi-
Personalize ences. New information is likely to be retained if
To be successful, the educational process has to it is linked or connected to something in the indi-
be both personal and personalized. Individuals vidual’s past experience. Learning new, uncon-
will ignore a plan that they perceive as being nected material is extremely difficult. Learning
generic or irrelevant to their needs. Cooperation tends to be cumulative. It requires time for them
can be built by having them involved in the plan- to understand, assimilate, and then manipulate
ning. Input will provide a sense of control and the information that is provided.
demand a degree of commitment from them— Hence, when teaching, it is important to have
after all, the plan belongs to them. If, for instance, a knowledge of their background and how much
an action plan does not take into account their they understand. The simple use of analogies
lifestyle, the result will be non-adherence. It is (such as the comparison between asthma control
important that the action plan target those goals and driving a car) builds pictures that make learn-
that the individual considers important. ing easier. Redness, swelling, and inflammation
Each lesson plan must be unique—a precisely can be compared to the result of a mosquito bite
identical educational approach cannot be used or poison ivy, pointing out the obvious different
with different individuals. Because they are indi- consequences when this happens in the lining of
viduals with their own particular needs and con- a tube compared with a flat surface. The stuffiness
cerns, every educational endeavor has to be and symptoms of a cold or hay fever can be com-
designed to meet their individual needs. There is pared to an asthma attack─congestion and runny
nose compare well with tightness of the chest and ment is more productive than delayed (or long-
excess mucus production. Simple examples term) reinforcement. This is one of the ways to
ensure that they understand. motivate them. While motivation for behavior
change must come from within the individual,
The Three Rs of Teaching the educator can provide some impetus and
Review. A good teacher will review what was encouragement.
explained not only in the last visit but what was Variety of media: There are many ways of
said at the start and middle of the current visit. A learning. Some people prefer visual rather than
review can take many forms, including asking the auditory media, while others would rather listen
individual to explain some item of information, than read. Some prefer to learn by doing (the tac-
or asking detailed questions to ensure compre- tile approach). Hence it is essential that both the
hension of what has been taught to date. information and education be provided in a vari-
Repetition alone does not ensure learning. If ety of methods, including charts, models, videos,
something is repeated in the same words and books, computer programs, video games, asthma
same tone, it will not only suppress responses, apps, and so on. They can be used as part of the
but produce fatigue. Repetition has to be done teaching or to provide reinforcement. Whatever
with care. Knowledge that is repeated frequently, the medium chosen, the educator must ensure
and in a variety of ways, becomes familiar and that the material is previewed or reviewed prior to
accepted. Hence it is extremely important to its use. Such a review will ensure that the mate-
repeat the information provided, not only orally rial is usable and accurate, and that it contains no
but also in writing. This will reduce any later con- unexpected items.
fusion. They should be provided with opportuni-
ties for practice, particularly of skills that are
required. Points to Ponder
Reassure. Individuals who require asthma There is no single educational method or
education can become discouraged at the many technique that works for every person.
steps required to achieve control. Every little step Education is a slow, individualized, con-
should be seen as progress and it is the asthma tinual process.
educator who must reassure them that they will
triumph. All learning takes time. In asthma they
need to understand what is happening in their
lungs, why it is happening, and what is causing it No one method works for every individual.
to happen. They need to learn avoidance tech- Similarly, there is no single technique that will
niques, the use of different medications and so ensure understanding by every individual. A
much more. It can be daunting. So reassurance single-focus approach will not be effective, but a
that they are making progress will build their combination of cognitive, affective, and behav-
confidence and sense of control. The belief that ioral elements, in the process of teaching, will be
they can control the disease (self-efficacy) will productive [114]. Education is a slow and con-
encourage them to do more, learn more, and tinual process, and one that needs to be constantly
achieve self-management. adjusted to the needs of the learner.
Reinforcement. It is important that praise—or
gentle correction (which is negative reinforce- Structure
ment)—be given where it is due. Praise and The teaching session must not only be structured,
encouragement will motivate them to improve or it must be obvious that it is structured. Individuals
enhance asthma-control behavior. Emphasis on want to feel that the educator has a plan for them,
the positive aspects almost always reinforces and that preparation has been made for their visit.
desirable behavior [113]. Immediate reinforce- Yet, too much structure can inhibit the knowledge-
transfer process, as can an atmosphere that tain cultures. Be aware of different cultural
appears so relaxed as to feel unstructured. norms in order to avoid giving offence.
Structure and flexibility go hand in hand. The • Ask open-ended questions. These are ques-
asthma educator should not be afraid to jettison tions that cannot be answered with a simple
initial plans in order to meet their more pressing yes or no. At the same time, stay away from
concerns. If they are worried about something, leading and probing questions that can make
getting rid of the worry is more important than them uncomfortable. One objective of any
abiding by the particular plan. meeting is to build a relationship of mutual
Like all skills, teaching does get easier with respect. Making a person uncomfortable will
practice. With practice, it will take just a not help.
moment to adjust plans, to eliminate what is not • Use every opportunity to encourage and
needed, and to adapt the plans to meet current praise, but be sincere.
needs. • Try not to interrupt. Interruptions may cause
the educator to miss a vital point that they are
Suggestions making. In many cultures, it is considered bad
Finally, here are some suggestions [94] to help manners to interrupt. Further, they may have a
refine teaching skills. completely different viewpoint than the one
anticipated, and the interruption may cause
• Practice teaching a family member before them to forget it or decide not to admit it.
actually teaching the individual. Clear, unam- • Use silence. Wait for a few moments after they
biguous directions come with practice and have finished speaking and before beginning.
experience. Use short sentences. Speak sim- This will ensure that nothing is missed. It will
ply, clearly and directly. Be direct, and us the also indicate that attention has been paid to
active voice. For example, say, “This medica- them, and their statements are being consid-
tion relieves symptoms such as shortness of ered, before the answer was provided.
breath and wheezing” instead of “Wheezing Remaining silent can be an effective tool to
and shortness of breath can be relieved by get them to talk.
using this medication.” • Accentuate the positive.
• Stay focused. A person who has a willing lis- • Avoid jargon.
tener may take the opportunity to tell what • Beware of statistics—each person is a unique
appears to be a complete life story. Steer the individual, and not just a statistic.
story gently away from matters that do not • Know yourself, and know them, so that all
relate to asthma. Ask questions to steer the teaching is individual-oriented.
conversation in the direction that will help • Remember the golden rule of teaching:
increase understanding of their needs. The –– Tell them what is about to be taught.
educator must be attentive to what is said and –– Then teach them.
to what is omitted, observing them carefully –– Then tell them what has just been taught.
for clues to aid assessment. • At all times, be professional.
• Obtain feedback, both verbal and non-verbal.
Nonverbal feedback may take the form of eye The educator must be flexible, adaptable,
contact or lack of it, or body posture. Adjust sympathetic, a good listener, and non-judgmental.
the approach according to their reactions, and In all probability, these qualities already exist—
cultural background. one merely has to remember to exercise all of
• Provide feedback, both verbal and non-verbal them at the same time when teaching. At the
(such as a smile or a nod), so that they under- same time, one cannot be all things to all people,
stand or feel that you are listening. Again, and this is where the Team Approach makes emi-
keep in mind that a nod may mean “no” in cer- nently good sense.
15.8 The Team Approach who recruits staff, selects support materials, and
to Teaching allocates necessary funds, through all the suc-
ceeding levels to the individual who is a partner
Asthma management requires a bio-psychosocial and co-manager of asthma. In between these two
approach [7]. This involves three areas: extremes are the physicians or other healthcare
providers, who are required to provide care con-
• Biological. Physiologic and pharmacological sistent with professional standards.
intervention and management are offered as It is the job of the Continuing Education
the status of asthma fluctuates. Coordinator to regularly provide asthma updates
• Psychological. Emotional needs and develop- to professional staff since they are all occasion-
mental requirements are taken into consider- ally called upon to provide asthma-related help.
ation and provided for in all aspects of asthma Pharmacists can help reinforce proper use of
management. devices by teaching correct usage. Facility man-
• Sociological. The individual and family are agers can provide space and items required for
integrated into the treatment plan. All social education. Nurse Supervisors can ensure that
contacts (family, school, work, play and peer) asthma devices and teaching materials are cur-
are considered and provided for. rent, in adequate supply, and suitable for the cli-
entele of the area. They can also be a part of the
Since these three areas are interdependent and teaching team. Case managers should coordi-
impinge both on the presentation and manage- nate home care and target at-risk individuals.
ment of asthma, a balance between them must be Counseling for these individuals can be pro-
strived for, and maintained, in order that guided vided by psychologists and social workers.
self-management be successfully achieved. Computer (IT) staff can help provide statistics
The asthma educator is part of a treatment and maintain records through appropriate
team, with the individual with asthma being the software.
most important player—the central member of
the team. The other members of the team (the
healthcare provider, the pharmacist and also pos-
sibly a specialist) may not appear as important, Case Study
but they too are essential to the effective func- Joanne Winder is newly pregnant.
tioning of the team. Each player in a team has Diagnosed with asthma in her early teens,
strengths and weaknesses. One player’s weak- she has been on medications for the last
nesses can be compensated by another player’s 10 years and is currently on Pulmicort
strengths. So too should it be with the Asthma 200 mg bid and albuterol prn. She is trying
Team. If a team works together over time, some to quit smoking. She wonders if her medi-
blurring of roles or an overlap of expertise occurs cation will affect her baby and her baby
that enhances team functioning. The qualities and will also have asthma. How will you answer
experience that each member brings to the team her?
should be considered. It is important for her to keep her asthma
The team should reappraise the educational under control since uncontrolled asthma
goals on a consistent and frequent basis, ensuring will be harmful to the growth and develop-
that each member is allotted sufficient time to ment of her baby. The medications will not
contribute to the proper functioning of the team harm the baby. However, if she continues to
[115]. smoke, that will affect the baby and
In a managed care setting [116] every staff increase the baby’s chances of developing
member should have some knowledge of asthma asthma.
care, from the chief administrator of the facility,
15.8 The Team Approach to Teaching 563
For the team to be effective, team members • Difficult individuals

must be open and honest with one another. They • Those having major problems with adherence
should cooperate, and should each be prepared to • Those individuals with severe and difficult to
step in, whenever necessary, to “cover” for control asthma
another member. There are generally two reasons
why a team is ineffective [115]. The first deals For every member of the asthma team, com-
with the team’s ability to cooperate. A report by mon sense, a genuine sense of caring, and com-
the British National Health Service suggests that passion are the best guides to dealing with
interpersonal jealousies are the primary cause for individuals with asthma.
dysfunctional multidisciplinary teams. The sec- The team approach also benefits the team
ond reason is the failure of health professionals to members. It provides:
realize how the information they provide to per-
sons with asthma is open to individual interpreta- • Peer support
tion that can result in misunderstanding and • Increased guidance
confusion. • Motivation for education of people with
If different members of the team meet with the asthma and their families
person with asthma and provide further educa- • Reduction of stress in the workplace
tion, it becomes even more necessary for each • Recognition for individual efforts
team member to keep a detailed written record of • Validation for efforts made
interaction with the person. The individual’s • Increased level of team work
responses must be reported. All pertinent infor- • Increased support from the healthcare
mation must be documented. In the absence of provider
one team member, another member must have • Increased support from administration
the necessary information available, in order to • Increased incentive to stay up-to-date with
help the person with asthma. current advances in asthma
Documentation provides for continuity of • Heightened professional respect
care. It helps team members identify the personal • Reinforcement of professional identity
goals that have been achieved to date and the
objectives and strategies required to achieve The team approach ensures that nothing is
desired goals. It tracks the individual’s progress done in isolation, and that education of the per-
in self-monitoring, and indicates the level of con- son with asthma is as important as the healthcare
fidence in being able to manage asthma. It should providers’ or other healthcare professionals’
measure the level of self-efficacy and motivation roles in asthma management. It shares the respon-
to control the asthma. It can assess the effective- sibility of education between the team members
ness of individual asthma action plans. so that the burden of education does not rest with
Documentation also prevents replication of one person alone. Properly done, it can be an
efforts that were unsuccessful, and is consider- exemplary model of group management with
ably useful in planning future teaching approaches each member’s role clearly defined.
for the individual with asthma. It empowers all team members, including and
Regular meetings of the professional mem- especially the person with asthma. When done
bers of the team can help coalesce or modify the well, the team approach to education results in
approach to be taken. The planned meetings, con- guided self-management of asthma by the indi-
ferences, or telephone consultations increase the vidual with asthma. Asthma educators who treat
level of communication between team members. the person with asthma as an individual and pro-
Such periodic meetings are extremely beneficial vide advice on self-management significantly
in dealing with: reduce both the suffering and the costs associated
with this chronic disease [117]. That is the aim of 2. Prepare a lesson plan outline using the three
all asthma education. domains, for dealing with an individual with
Effective teaching results from meeting the EIA who is afraid to exercise. Explain how to
needs expressed by the individuals themselves. evaluate their progress and the learning prin-
Moreover, it must conform to their perspectives ciples that were applied for each domain.
on health, illness, and recovery [46]. Successful 3. In Chap. 17 of this book, do case studies num-
learning requires continuity and consistency. bers 13 and 14.
There must be consistency in attitude, content,
and method. Lack of consistency in teaching
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Clinic Management and Evaluation
16
Contents
16.2 Running an Asthma Clinic 571
16.2.1 Facilities 572
16.2.2 Time 572
16.2.3 Equipment and Materials 572
16.2.3.1 Peak Flow Meters 572
16.2.3.2 Placebo Devices 573
16.2.3.3 Peak Flow and Symptom Diaries 573
16.2.3.4 Asthma Action Plans 574
16.2.3.5 Quality of Life (QOL) Scores 574
16.2.3.6 Information Leaflets 574
16.2.3.7 Books and Internet Materials 574
16.2.3.8 Visual Aids 575
16.2.3.9 Computer-Assisted Learning (CAL) 575
16.2.3.10 Records 575
16.2.4 Telemedicine 576
16.2.5 Resources 577
16.2.6 Evaluation of Teaching Materials 579
16.2.7 Education Programs 580
16.2.8 Planning 580
16.2.9 Costs 581
16.2.10 Data Collection 581
16.2.11 Standards 581
16.3 Teaching in the Home 584
16.3.1 Assessing the Environment 584
16.3.2 The Home Teaching Kit 586
16.4 The School Environment 587
16.4.1 Classroom Assessment 587
16.4.2 Within the School 588
16.4.3 Outside the School 588
16.4.4 School Policies 589
16.4.5 Physical Education 590
16.4.6 General Education for School Staff 590
16.4.6.1 Parents and School 591
16.5 Evaluation of Education Programs 591
16.5.1 Designing an Evaluation Program 592
570 16 Clinic Management and Evaluation
16.5.2 Establishing Standards 595

16.5.3 Data Collection 596
16.5.4 Data Analysis and Evaluation 596
16.5.5 Review 597
16.5.6 Confidentiality 599
16.6 Self-Evaluation 599
16.6.1 Using the Self-Evaluation Checklists 600
16.7 Self-Evaluation Checklists 601
16.7.1 Checklist 2 603
Appendix 16.1 605
Reading Material for Patients 605
Appendix 16.2 605
Internet Addresses 605
General Interest 606
For Asthma Educators (Not for Patients) 606
Appendix 16.3 606
Suggested Reading for Asthma Educators 606
References 607
Key Points • The school environment both inside and

This chapter covers the following: out, classroom assessment for triggers:
–– School policies
• The various aspects involved in running –– Physical education
an asthma clinic from facilities to time, • General education for school staff and
including: parents
–– Essential equipment and materials— • The self-evaluation required to become
placebos, leaflets, visual aids a successful asthma educator
–– How to evaluate teaching materials
–– The importance of records and
appropriate resources
–– Use of telemedicine with appropriate Chapter Objectives
prior education of users After reading this chapter, you should be
• How to evaluate education programs: able to:
–– Items to consider when setting up an
evaluation program 1. List the requirements for setting up and
–– Data collection, analysis, evaluation, running an asthma clinic
and standards 2. Discuss the purpose of evaluation and
• Considerations when teaching in the its role in designing any asthma educa-
home and includes: tion program
–– Assessing the environment 3. Evaluate asthma education materials
–– The home teaching kit 4. Determine your level of skill in organiz-
ing, managing, and teaching and be able
to evaluate the work you do
16.1 Introduction • Time

• Equipment and materials
Asthma clinics currently exist in a variety of • A plan
locations. One of the stimuli that led to their • Financial support
establishment was the realization that asthma • Medical and clerical support
mortality studies from different communities, in
different countries, clearly indicate that most The effectiveness of the asthma educator (and,
deaths are associated with poor or inadequate by association, the clinic) will be determined by:
care or with poor adherence to advice. Therefore,
many of these asthma deaths might be prevent- • Knowledge and confidence
able. There was also a realization that asthma • The relationship between the educator and
care for individuals might be improved, with local healthcare providers
resultant decrease in costs [1, 2] and simultane- • The willingness of healthcare providers to
ous improvement in quality of life. allow the educator to work with individuals
Some clinics are located in hospitals and oth- with asthma and their families
ers in group practices or in health centers. Some • The relationship established between the edu-
are independent. Whatever the location or for- cator and those same individuals
mat, certain general principles apply. The best • The level of mutual trust that is established
clinics have an underlying philosophy that fosters • The clinic’s finances
and supports individual self-management. This
chapter will briefly discuss those principles that All of these are important. Healthcare provid-
should be considered in running an asthma clinic. ers’ knowledge and interest in asthma vary con-
In many clinics, the asthma educator, what- siderably [3, 4], and this variability will affect the
ever their background, be it nurse, respiratory professional relationship between them and the
therapist, pharmacist, or healthcare worker, may educator. There will also be wide ranges in their
also be the office manager and official statisti- confidence and comfort level in dealing with the
cian. While front-office duties—such as record educator and in having the educator work with
keeping, booking of appointments, and general individuals with asthma.
accounting—may be handled by a receptionist, it The asthma educator will be fully effective
will most often be the responsibility of the asthma only if sufficient time is taken to meet the needs of
educator to manage the clinic so that it operates those with asthma. Education requires a great deal
both effectively and efficiently. of organization—of time, materials, and method.
Office management is beyond the scope of It also demands an ongoing assessment of the indi-
this text, and there are many excellent books vidual’s ability to understand and ongoing changes
available which describe and analyze the topic in in teaching technique to adapt the material to their
depth. This chapter will deal with those office understanding. It may even require that special
elements that affect the asthma educator’s ability materials be prepared to suit them, should there be
to educate and those to which special attention no materials that are either suitable or available in
should be paid. their language. In other words, an educator with an
excessive administrative workload will become a
very ineffective educator.
16.2 Running an Asthma Clinic Education is time-consuming. Each teaching
session requires preparation. Thus, to be effec-
To run an asthma clinic effectively, the following tive, it is essential that the educator know how to
are needed: manage both personal time and the time spent
with those who request help. Teaching cannot be
• A trained and qualified educator hurried but it can be postponed. An effective edu-
• A location cator will know how and when to do so.
16.2.1 Facilities • Complete teaching-related paperwork

• Administer the clinic
Education cannot be done in a public area, nor • Conduct interviews
should it be done in different rooms at different • Evaluate and select new teaching materials
times. Those with asthma will feel unsettled and • Perform teaching-related research
uncomfortable if there is a lack of privacy or if they
are shuffled from one room to the next. A “teaching The initial education session with someone
room” area should be set aside specifically for newly diagnosed with asthma may require
asthma education, so that individuals with asthma between 30 minutes to 1 hour, depending on the
become familiar with it and are comfortable within number of questions posed and the need to go
it. It should have a table, chairs, and teaching sup- over basic asthma information, allay fears, give
plies but no sources of interruption. reassurance, and provide initial education. It will
Such an area also facilitates the work of the also depend on their ability to concentrate and
educator, since all educational materials can be pay attention. Follow-up appointments can be
organized and stored within it for easy retrieval. scheduled to last 15 minutes.
This is particularly important since different indi- Education requires time, and each and every
viduals will require different materials, depend- person should rightly expect to have the complete
ing on their needs. and unhurried attention of the educator when
If the clinic has two or more telephone lines, they arrive for an appointment. This means care-
one of these lines could have a menu that allows ful time allocation and equally careful monitor-
for contact with the asthma educator. Voice mail ing of the workload.
will facilitate the ease with which they are able to At the same time, no attempt should be made
contact and inform the asthma educator of their to rigidly adhere to a teaching schedule that has
needs. It permits contact with those individuals been developed for an individual since their
who require a follow-up. Moreover, it will make needs take precedence over educational plans.
the educator appear far more accessible. This may There may be concerns about medications and
seem like a trivial matter, but it will be very reas- their side effects, or they may have new concerns
suring for them to know that they can leave a mes- or be uncertain about material discussed in a pre-
sage for the asthma educator. However, some may vious session. They may need anticipatory guid-
regard this as a further obstacle, and older adults ance for a coming event. Teaching flexibility is
may have some difficulty using the telephone. It hence very important. During each visit, there-
may also be a hurdle to those individuals who fore, it is preferable to address their most press-
have difficulty communicating in English [5]. ing needs and concerns and to schedule another
Voice mail allows the phone to be kept out of visit to complete the teaching, rather than to try
the education room—interruptions should not and accomplish everything in an arbitrary allot-
occur while teaching is in progress. Some indi- ment of time.
viduals may initially be uncomfortable with
voice mail but will be reassured when they real-
ize that it allows completion of an education ses- 16.2.3 Equipment and Materials
sion without interruption and that their calls will
be returned within a designated time frame. In addition to normal office supplies and furnish-
ings, asthma-related materials will also be
required, including the following.
16.2.2 Time
16.2.3.1 Peak Flow Meters
The educator must have adequate time each day to: There should have an adequate supply of dispos-
able mouthpieces. PFMs are an important tool in
• Teach asthma management, yet some individuals may
be reluctant to purchase them. For them, a hands- sometimes helpful to show them what is available
on trial may be a simple way of convincing them and then allow them to decide which device they
that the meters are well worth acquiring. They are will use, provided this is acceptable to the health-
more critical for individuals with moderate to care provider. After they have chosen a device,
severe asthma. they will need instruction in its use and care. This
Peak flow meters are not “precision” devices. is where the placebo is extremely useful. An
Readings will vary between two identical mod- actual demonstration followed by their use of a
els, and between competing brands [6]. Once the placebo device is “worth more than a thousand
individual has purchased their own meter, they words,” and the educator will immediately be
should be encouraged to bring them into the able to note those areas that need additional
clinic each time they come in so that consistent instruction and/or correction.
readings can be obtained. Further, this will give
the educator an opportunity to see how the device 16.2.3.3 P eak Flow and Symptom
is used and treated and whether it is in proper Diaries
condition. With time, the spring inside the PFM These are available from the major pharmaceu-
will lose its stiffness, becoming more elastic, and tical companies and from select publishers.
provide an improperly high reading, at which They can also be downloaded from the Internet
time the device should be replaced and a new at no charge from many asthma-related
“personal best” reading obtained using the new websites.
meter (Figs. 16.1, 16.2 and 16.3). There are numerous diaries of all sizes and
shapes available through pharmaceutical compa-
16.2.3.2 Placebo Devices nies and websites; some are more suited to indi-
Placebo medication-delivery devices have many vidual education. Choose ones that reinforce the
uses: they aid in device selection, user training, traffic signal concept by providing full-color
and follow-up. They are an important tool in the depictions of the peak flow zones. They become
clinic’s arsenal. visual teaching aids and will provide individuals
The device a person uses must be carefully with asthma with visual warnings when their PEF
chosen to suit the person’s age and needs. It is readings start to fall from the green into the yellow
Fig. 16.1 A selection of the manual PEFMs available

guide the person with asthma and indicate what

to do when PEF readings fall below 80, 60, or
50% of personal best. They also contain the
written instructions to use at home when asthma
deteriorates.
The forms are a vital component of any asthma
self-management plan, and asthma education
would be incomplete without them. Note that
they must be completed properly if they are to
function as a written record for both the individ-
ual with asthma and the healthcare provider.
They must be consistent with the literary level of
the individual. The asthma action plan reinforces
the fact that there is more to asthma management
than just taking the required medication.
Fig. 16.2 Peak flow meter linked to a smartphone. (©
Medical International Research)
The action plan must be written in the lan-
guage that the individual prefers, particularly if
they are not comfortable with English. While this
may require the assistance of a translator, it has a
greater chance of being followed than a plan that
is written in a language unfamiliar to the
individual.
16.2.3.5 Quality of Life (QOL) Scores

QOL scores are important. They help evaluate
the impact of asthma on each individual and are
one more tool to judge the effectiveness of both
the medication regimen and the education pro-
vided. (See Chap. 6, Table 6.10 for a variety of
tested QOL scores.)
Fig. 16.3 A pediatric (low-range) peak flow meter with
an aid to teach children how to blow correctly 16.2.3.6 Information Leaflets
These are available at no charge from a number
of sources, including pharmaceutical companies
or red zone. (Note, though, that they will not prove and some of the larger pharmacy chains. They
useful with people who are color-blind.) can also be purchased from many asthma and
A comprehensive four-color diary is available allergy support organizations for a fee.
from the allergy and asthma teaching unit in
Vancouver, Canada. It combines peak flow read- 16.2.3.7 Books and Internet Materials
ings with symptom scores and uses a very effec- Everyone with asthma should be made aware of
tive credit card-sized asthma management plan. the material that is available to help them sup-
The credit card asthma management plan has plement the information provided in the clinic.
been used successfully in New Zealand [7]. A list of recommended books and reliable web-
sites should be given to every person with
16.2.3.4 Asthma Action Plans asthma. This list should be kept up to date and
Printed forms describing these plans are avail- should include, for example, the books in
able from pharmaceutical companies, from Appendix 16.1 and some of the websites listed
select publishers, and on the Internet. They in Appendix 16.2.
Fig. 16.4 Models
showing normal and
inflamed airways
16.2.3.8 Visual Aids choose specific questions and ignore others and
Since individuals learn in different ways, it is to work at their level of knowledge.
essential that different visual aids be readily Teaching programs such as Compliance for
available; further, the educator should be pre- Asthma; Watch, Discover, Think and Act; Air
pared to try different teaching approaches. This is Academy: the Quest for Airtopia; Quest for the
particularly important when teaching children Code; and the Asthma Files—to name a few—are
and young adults or persons who have no knowl- available, interactive, and consumer responsive.
edge of anatomy. Visual aids such as charts, mod- Quest for the Code is available online with a par-
els, and videos can all be used. Many of these are ent’s guide in both English and Spanish.
available at no cost from pharmaceutical compa- Lungtropolis: Attack of the Mucus Mob and
nies (Fig. 16.4). Wellapets are also available online. Studies have
been done to show their effectiveness in increas-
16.2.3.9 Computer-Assisted Learning ing the knowledge of individuals with asthma
(CAL) [8–10]. While all the games available have been
Many asthma clinics use computers to provide shown to result in an increase in knowledge of
information and interactive learning about asthma and motivation, they have not shown to
asthma. Technology allows more sophisticated change behavior or clinical outcomes [11–13].
education on an individual basis. For example, An important development in asthma educa-
interactive programs such as Bronchi the tion is the asthma app, which runs on mobile
Bronchiosaurus (Nintendo), Wee Willie Wheezie devices such as mobile phones and tablet com-
(PC), Kid Breathe, and Asthma Command give puters such as the iPad (see Chap. 15). While
control of education to the patient. Consumers of there are numerous computer-assisted teaching
healthcare and experts have collaborated in aids available today, nothing has proved more
developing computer-assisted learning programs successful than personal education by a live
and chosen appropriate questions with consistent asthma educator [14].
and accurate answers. For the individual, the
response can be sought as often as desired, until 16.2.3.10 Records
it is understood. The computer provides the same A conscientious educator must maintain records
answer each time and never gets impatient. CAL for each individual. These may be electronic or
can also be designed to allow individuals to paper-based. They must be easily retrievable but
securely stored as the need for confidentiality is individual’s asthma. Some allow an individual to
important. keep track of PEF readings through the Internet,
A computer-based “patient management sys- and others record information for clinical staff.
tem” or “patient recording system” can be very For example, Linkmedica (part of the Health On
helpful in keeping track of individuals with the Net Foundation) includes an automated diary
asthma, recording the educator’s notes, and main- that allows individuals to record their daily peak
taining the necessary follow-up. A number of flows. It then provides immediate feedback on
software packages have been designed specifi- the degree of control by comparing the peak
cally for asthma clinics. One of these, Palm flows against the individualized asthma plan pre-
Asthma offers templates so that every encounter pared by their personal healthcare provider. This
with an individual can be documented. It records site also generates graphs of their peak flows and
identification information and then offers a four- graphs of pollen levels for the same period and
part program that covers the individual’s history location, thus allowing healthcare personnel to
since the previous visit, physical examination, modify the asthma action plan. Individuals with
assessment, and future plan. Available to health- asthma are sent reminders by e-mail or by text
care providers from the Yale Center for Medical message to cellular telephones.
Informatics (http://ycmi.med.yale.edu), it also
provides recommendations and suggestions
according to the NHLBI guidelines as to the clas- 16.2.4 Telemedicine
sification of severity and the appropriate pharma-
cological therapy and dosages. It calculates peak Technology has made contact between individu-
flow variability, presents information in graphical als and healthcare providers easier.
form, and at the end of the individual’s visit will Telemedicine—consultation by phone or video
print out prescriptions and handouts in both link—is not a new frontier in treatment. There
English and Spanish at standard- or low-literacy has been a significant but overlooked segment of
levels. The computer program also collects infor- the telemedicine industry that provides direct-to-
mation in a database to provide an overall view of consumer (DTC) services. From 2018 to 2019,
the patient base. Palm Asthma is an advance on more than a million visits were made to DTC
AsthMonitor, which was designed by the same companies such as Teladoc, Doctor on Demand,
organization for use in the management of acute and American Well, to name a few [17]. A study
asthma [15]. of users [18] of DTC telemedicine found that
In order to adjust each individual’s treatment, generally they:
quick access is needed to current and past treat-
ment history, response to medication, and pre- • Were female with the mean age of 36 years
scribed dosages. Electronic medical records • Live in urban, high-income areas
(EMR) now tend to be the norm over paper-based • Live in an area with a shortage of primary care
records, because they make it easy to identify providers
individuals who have risk factors for asthma or
recurrent asthma exacerbations and to improve Most visits took place outside the normal
treatment. Automated chart reviews are useful working hours of healthcare providers.
particularly for asthma epidemiologic studies The many restrictions imposed by the
with appropriate ethics oversight since a manual Covid-19 pandemic of 2020 have resulted in an
review of diagnostic codes is both labor- and increased use of “virtual” visits using telemedi-
time-intensive [16]. cine which has three formats—remote monitor-
Advances in technology and the increased use ing, interactive, and “store and forward.” Remote
of the Internet have resulted in some asthma- monitoring allows the healthcare provider to
related services now being available online so adjust treatment without waiting for a clinic visit.
that the clinical team can remotely monitor an While not successful, by itself [19] it has proved
valuable when combined with education [20] or encing due to a lack of experience. They may also
with the use of electronic reminders and feed- have problems such as diminished vision or hear-
back [21]. ing or cognitive decline that makes telemedicine
A recent study showed that telemedicine difficult. Many may also lack access to a com-
(using only the telephone) visits for inner city puter, a smart phone, and a high-speed Internet
children with asthma increased during the connection.
Covid-19 pandemic replacing regular visits to Older adults will accept telemedicine if:
healthcare providers. Using the asthma control
test (ACT), over 90% rated their asthma as well • They consider it useful
controlled. In a comparison with regular visits, • It does not require too much effort
the healthcare provider and staff from the • They have a social milieu to which it is
Breathmobile found that the time spent with each familiar
person with asthma using telemedicine increased • They consider it private and secure
by 32–62% compared against in-person visits. • They have no qualms about using a computer
Telemedicine provided a better experience for • They own and are familiar with using video
both provider and patient [22]. components
It is important that those with asthma be told
that a telehealth or virtual visit cannot always and Their physician’s opinions may be an influ-
entirely replace an actual visit. They will need encing factor [23].
guidance on how to approach a telemedicine visit. Many seniors, particularly those on Medicaid,
Suggested guidelines include the following: have low socioeconomic status and likely to have
some form of disability due to comorbid condi-
1. Know what they want to talk about—this
tions [42, 25]. The ability to use technology will
means a list of symptoms, how long since the determine its acceptance by them.
symptoms started, and how are they trending, In an asthma clinic, it is essential to decide
questions they need answered, and other notes what kind of telemedicine can be offered—tech-
that they feel may be essential for the physi- nology that is compatible with the electronic
cian to know about. health records and that can be easily integrated
2. Test the virtual appointment prior to the actual into the functioning of the clinic.
appointment to make sure the Internet connec- Digital health services include not just health-
tion is good and that the audio and camera are care provider offices, but their reach has expanded
working. Use a blank wall behind where they to include clinics, hospitals, pharmacies, health
are seated and make sure that there is good insurance companies, and grocery store chains
lighting so that they can be seen clearly by too. Privacy concerns and security of information
their physician. must be paramount in using digital products for
3. Review the list prior to the call. Keep the list telemedicine. Telemedicine can help reduce
of topics, a pen, and paper at hand in order to health disparities and provide equitable access to
make notes during the call. health services for low-income and vulnerable
4. Sign on prior to the appointment. Make sure individuals.
they are in a quiet room where they will not be
disturbed. They should have all their medica-
tions and devices next to their pen and note- 16.2.5 Resources
pad so they can refer to them as needed.
5. They should know when they must go in for a Every individual with asthma must be reminded
personal visit. that the Internet today is completely unregulated.
Any person, honest or otherwise, can set up a
The asthma educator should be aware that website and use it to promote fake statements and
many seniors have difficulties with videoconfer- unfounded claims, publish legitimate-sounding
but false articles, and sell unproven cures. The • Dictionaries, with spelling and definitions of
old Latin maxim caveat emptor—buyer beware— medical terms.
has never been more true than on the Internet. • Directories.
Computer-literate individuals may request a • Other resources, such as consumer libraries.
list of asthma-related Internet sites. They should • Current health news. This may contain items
be reminded that, when browsing, they should of interest to those with asthma.
look at the source of the information, decide how
reputable or reliable that source is, and avoid While the pharmaceutical companies are a
sites that are suspect in any way [26, 27]. This source for educational materials, there are other
also applies to “chat rooms” wherein total strang- organizations, local, regional, and national, that
ers can hold conversations in conditions of total can also provide necessary information. These
anonymity and promote fake cures. For a list of include many reputable organizations in the field
recommended sites, see Appendix 16.2 at the end of asthma and allergy. Here are a few:
of this chapter. See Fig. 16.5 for criteria to use
when evaluating a website. Allergy Asthma Foundation of America
Literacy levels are a concern when individuals Food Allergy and Anaphylaxis Network
wish to read education materials on the web. A Allergy and Asthma Network
study by D’Alessandro et al. [28] found that most American Lung Association
materials were written at a grade 12 reading level Regional lung associations
and hence were not appropriate for the average American Academy of Allergy, Asthma, and
adult. Immunology
One of the best sites for health-related informa- American College of Asthma, Allergy and
tion for consumers is maintained by the US gov- Immunology
ernment at www.nlm.nih.gov.medlineplus. It American College of Chest Physicians
presents the viewer with articles on the following: American Thoracic Society
American Association for Respiratory Care
• Health topics. National Jewish Medical and Research Center
• Drug information. (Lung Line)
Health Oasis—Mayo Clinic
US Department of Health and Human Services
Criteria for choosing web sites International Food Information Council
Local support agencies may also exist. Self-

Check for
help groups are a tremendous resource.
Up to date content
Comprised of people who have the same con-
Reputable and reliable content
cerns, they offer shared experiences and a collec-
Reputable sponsor/author or
tive approach to solving problems. They offer
developer
empathy, support, and understanding and can be
Frequency of update
a powerful incentive to behavioral change, to
Level of literacy increasing the motivation to learn and the mainte-
Site maintenance nance of new behavior [29]. In other words, they
Accessibility can promote the three fundamental stages of
Availability change: motivation and commitment to change,
Ease of use and navigation initiation of change, and maintenance of change,
Aesthetics – pleasing to the eye thus ensuring that the changes are not
temporary.
The asthma educator should investigate local
Fig. 16.5 Criteria for choosing websites resources including:
• Healthcare agencies and clinics • Illustrations and clarity of diagrams

• Community service agencies • Any special features—color, style, pull-out
• Family counseling and mental health services tabs, etc.
• Health maintenance organizations • Cultural sensitivity (no racially offensive
• Health departments of cities or regions material or stereotypical depictions of people,
• Societies established to help people with spe- etc.)
cific health diseases such as allergy sufferers • Conflict with personal values
or people with asthma • Balance—whether the material is presented in
• Hospitals an impartial and balanced manner
• Local or state universities that are interested in • Date and year of publication
health and have materials for health education
• Vocational rehabilitation centers When using materials from pharmaceutical
• Local chambers of commerce, which will companies, it is important to remember that
often have lists of clubs and churches involved because these are in effect a form of advertising,
in health education they must be carefully checked to ensure that
• Health-oriented organizations such as the they do not promote a single medication as being
YMCA, YWCA, and Red Cross a cure or solution for asthma. Information on
• Pharmacy chains environmental control may be given but it is
unusual for it to be highlighted. Emphasis on tak-
Local or regional television companies may ing medication without a corresponding empha-
have documentaries or health-related programs. sis on environmental control provides an
Federal government organizations involved in inaccurate and misleading message.
healthcare and maintenance provide excellent It is important not to overestimate a person’s
educational materials. In addition, the Federal literary level. Like all other skills, reading skills
Consumer Information Center offers a catalogue require practice if they are to be maintained, and
that lists available federal publications under var- too often individuals do not read at the level of
ious health categories. education they have completed [30–32]. The
incidence and prevalence of low literacy are gen-
erally not recognized [33]. Most adult Americans
16.2.6 Evaluation of Teaching read at a grade 6 level. One in five is functionally
Materials illiterate. Persons in low socioeconomic groups
read at a grade 3 level [34]. Most education mate-
While there are many resources available for rial tends to be written at a grade 11 level [35] (or
teaching individuals about asthma and allergies, above, even to the level of college reading and
the educator should carefully evaluate them and comprehension [36]) making it difficult to under-
their sources for: stand. When giving printed material to an indi-
vidual, it can hence be very helpful if the educator
• Suitability explains and identifies any difficult words.
• Accuracy Conventional education materials are unsuit-
• Age-appropriateness able for individuals who read below a grade 4
• Appropriateness of content level, but it is possible to adapt these materials for
• Content—is the information current? their use [37].
• Ease of comprehension Available materials must comply with the lat-
• Clarity of content est asthma guidelines, be accurate in content, be
• Reading level or level of literacy up-to-date, and be dated so that obsolete material
• Presentation (whether visually appealing) can be discarded. A study by Smith and Gooding
• Professional appearance (size of typeface, [38] evaluated 168 leaflets received from prac-
fonts use, layout) tices in Britain. It found that 78 were not in
accordance with British Asthma Guidelines; 11 been done to evaluate the effectiveness of these
were not accurate (of these, 5 were produced by programs and the conceptual models on which
pharmaceutical companies and 7 contained out- they are based. A review of these studies will
dated therapeutic advice); and 34 contained inac- make the choice easier.
curate or misleading statements on areas outside
the guidelines, such as incorrect contact num-
bers, misinformation, and inexact advice. An 16.2.8 Planning
Australian study [39] found that one-third of the
adult asthma education pamphlets were written at A plan is only as good as the people who imple-
or above grade 9 and two-thirds at or above grade ment it. If the individual’s healthcare provider is
8, so that they were beyond both the reading and not supportive of asthma education, there is very
comprehension ability of the target population. little the asthma educator can do. A healthcare
Materials must be reviewed regularly and provider who is interested in asthma care will
updated regularly. Everyone has a right to good, actively encourage asthma.
current, and accurate advice, and so the asthma An educator cannot be totally independent but
educator should carefully select materials that are must function as part of a physical or virtual team
clear and up-to-date in their message; simple in whose members communicate and cooperate
presentation; appropriate both to age, culture, with one another. The educator, the healthcare
and literacy level; and suitable to the individual. provider, and the individual with asthma will
It is advantageous to have a wide variety of mate- comprise the basic unit but the team can be
rials available so as to be able to select what is expanded as required to include many other
required for each person. health professionals. Within the team, though, the
educator may find themselves in a somewhat
“gray area” with vaguely defined borders. For
16.2.7 Education Programs this reason, they will need a clear, unambiguous
set of rules or guidelines, drawn up in collabora-
As mentioned earlier, there a numerous software tion with the healthcare provider that specify
games and programs available. Programs what the educator should, can, and cannot do.
designed specifically for school-age children [40, Protocols that clearly define areas of responsibil-
41] in residential care, summer camp, commu- ity in the treatment of the individual with asthma
nity, home administered, school-based [40], and will have to be established. These rules should be
outpatient settings are also available. A smaller more detailed than found in a typical job
number exists for adults and teenagers and for description.
individuals with low literacy skills and who come Depending on the relationship with the health-
from a low socioeconomic group [43, 44]. care provider, the asthma educator may be asked
Care must be taken to ensure that the program to help with diagnostic testing, to write prescrip-
chosen is suitable for each person’s literary level, tions, and to even suggest medications or changes
culture, and the teaching setting. To be avoided to the medication regimen of the individual. All
are those programs that seek only to provide these job responsibilities must be clearly speci-
knowledge of asthma and that are not based on fied in the guidelines that govern the position of
behavioral and educational theories, particularly asthma educator.
those designed for adults. Vertically designed Over time, the educator’s skills will improve,
programs (those that provide one-way instruction and the healthcare provider’s confidence in the
and those that do not encourage interaction as educator’s ability will increase. For this reason,
well as problem-based learning) are not helpful periodical meetings with the healthcare provider
for individuals who need to focus on dealing with should be scheduled to jointly review and adjust
the disease and the practical application of the guidelines pertaining to the scope of the edu-
asthma knowledge. Studies [40, 45–58] have cator’s job.
Consider too the follow-up method that should 16.2.10 Data Collection
be used with the individual with asthma. For
example, should they see the healthcare provider Once the clinic is up and running, data must be
on each visit or should they first see the educator? collected. Any new clinic will opt to use an elec-
Should they always see the educator and see the tronic health records (EHR) system rather than
healthcare provider only when required? Because maintain paper-based files. Before selecting a
financial arrangements differ from one area to the system, careful thought must be given to (a) the
next, each clinic must make its own decisions in reports and analyses that the system should be
this matter. capable of delivering and (b) the amount of raw
data the system will need before it can produce
those reports. A review of the costs versus the
16.2.9 Costs benefits for these two items will make it easy to
select the new system.
The scope of any business plan will be dictated A good system will easily provide answers to
by the money available. There will be many costs, such questions as “Which individuals work in a
including: sawmill?” or “Who is our oldest widowed male?”
(This last question, for example, requires that
• Salary for the part-time or full-time asthma gender, marital status, and age be collected.) The
educator importance of good statistical data cannot be
• Office rent overstated—the better the data, the better the
• Educational materials information that can be derived from it.
• Placebos A number of clinic-related software packages
• Telephone are currently available. For example, the Yale
• Record-keeping costs for both individual Center for Medical Informatics offers the Palm
records and education records Asthma system. Other commercial systems, such
• Office supplies as HealthEngage, are also available. FireLogic
• Administrative costs Inc. offers a 5-day trial version of its software.
• Costs for the educator’s time when not Most suppliers will offer free trials, and new sup-
teaching pliers will emerge at regular intervals and will
undoubtedly be found on the Internet. As with all
Education is time-consuming which makes it products and services on offer, these too would
expensive. Further, the materials required will have to be evaluated to determine whether they
need to be bought, from the placebo devices to the are reliable, supported by the supplier, and meet
educational aids. Time will be required to collect the clinic’s needs and usability requirements.
and evaluate them. Time will also be required to
update all teaching materials, ensuring that they
are current. Time is money and thus costs will be 16.2.11 Standards
a major consideration in running an asthma clinic.
The administration department may not The success of the clinic will be judged on a vari-
understand the costs involved and may require ety of criteria. While there are no generally
proof of the effectiveness of the education pro- agreed standards for asthma clinics, ten basic
grams. Hence, evaluation of education programs components should be considered. They include:
becomes even more important, and the cost of
this evaluation has to be included in the cost of 1. Needs assessment. Each individual’s needs
running an asthma clinic. Costs will be related to must be assessed during a personal
the number of healthcare personnel involved and interview.
the number of individuals who require 2. Planning. The educator must develop plans
education. that meet their needs and concerns.
3. Program management. An individualized 2. The asthma clinic will determine its target
program must be prepared for every population, assess educational needs, and
individual. identify both the barriers and the resources
4. Communication. Communication between necessary to meet the self-management edu-
individual and healthcare professionals must cational needs of the target population.
be emphasized, as must coordination between 3. An established system involving profes-
team members in the teaching process. sional staff and other stake holders will par-
5. Access. Individuals with asthma must have ticipate annually in a planning and review
ongoing access to teaching. process that includes data analysis and out-
6. Content. The material taught must be appro- come measurements, and address commu-
priate, and there must be consistency in what nity concerns.
team members say and teach. 4. The asthma clinic will designate a coordina-
7. Instructor. Any team member may assume tor with academic and/or experiential prepa-
the role of the teacher, but there must always ration in program management and the care
be a knowledgeable person involved in the of individuals with chronic disease. The
teaching process. coordinator will oversee the planning, imple-
8. Follow-up. This is absolutely vital. mentation, and evaluation of the asthma clin-
Reinforcement, reassurance, and repetition ic’s programs.
are critical for learning, and a single meeting 5. The asthma clinic will require the interaction
is inadequate for teaching purposes. of the individual with asthma with a multi-
9. Evaluation. This has to be done continuously faceted educational instructional team.
and involve evaluation of the instructor, the Instructional staff must be certified asthma
teaching, the individual, and the program. educators (AE-C) or have recent didactic and
10. Documentation. Record keeping is funda-
experiential preparation in education and
mental to any style of evaluation. asthma management.
6. The instructors in the asthma clinic will
Any asthma clinic, whether staffed by one obtain regular continuing education in the
person or by a team of healthcare professionals, areas of:
must perform these basic functions if any form of • Asthma management
effective asthma education is to be achieved. • Behavioral interventions
In many ways, asthma education is indebted to • Teaching and learning skills
diabetes educators who have been pioneers in • Counseling skills
education and advocates for the concept of self- 7. A written curriculum, with criteria for suc-
management. The task force of the National cessful learning outcomes, shall be available.
Standards for Diabetes Self-Management Assessed needs of the individual with asthma
Education [59] (sponsored by the American will determine which of the content areas
Diabetes Association) has set standards that are listed below are delivered:
as applicable to asthma education as they are to • Describing the disease process and treat-
diabetes. If these guidelines were to be adapted ment options
for the purposes of asthma education, they would • Incorporating appropriate environmental
read as follows: controls
• Utilizing medications for maximum
1. The asthma clinic will have documentation effectiveness
of its organizational structure, mission state- • Monitoring peak flows and symptoms
ment, and goals and will recognize and sup- and using the results to follow an action
port quality education for asthma plan
self-management as an integral component • Avoiding and minimizing exposure to
of asthma care. triggers
• Preventing, detecting, and treating acute on clinical guidelines or evidence-based

asthma episodes practice
• Goal setting to promote health • Tailors treatments and intervention to individ-
• Problem-solving for daily living ual needs
• Integrating psychosocial adjustment to • Promotes the flow of the participant’s infor-
daily life mation across settings while providing secu-
• Promoting management during rity and privacy in the interest of protecting
pregnancy their rights
8. An individualized assessment, development • Analyzes and uses data to continually improve
of an asthma educational plan, and periodic treatment plans
reassessment between individual and • Evaluates ways to improve performance and
instructor(s) will direct the selection of clinical practice, thereby improving partici-
appropriate educational materials and pant care
interventions.
9. There shall be documentation of the individ- DSC certification [61] is based on assess-
ual’s assessment, asthma education plan, ment of:
intervention, evaluation, and follow-up in the
permanent confidential education record. • Compliance with consensus-based national
Documentation will also provide evidence of standards
collaboration among instructional staff, pro- • Effective use of clinical practice guidelines to
viders, and referral sources. manage and optimize care
10. The asthma clinic will utilize a continuous • Performance measurement and improvement
quality improvement process to evaluate the activities
effectiveness of the education experience
provided and determine opportunities for JCAHO evaluates the degree of compliance
improvement. with standards in program management, clinical
information management, supporting self-
Apart from these suggested guidelines, there are management, delivery or facilitating clinical
other reasons for maintaining standards. The Joint care, and performance measurement. DSC certi-
Commission on Accreditation of Healthcare fication requires demonstration that periodic rou-
Organizations (JCAHO) advocates documentation tine analysis of performance occurs with the
of the organizational structure, goals, channels of intent to identify and address improvement
communications, and particularly the organiza- opportunities. It also requires a plan for measure-
tion’s commitment to educational programs [60]. ment of improvement and proof of improvement
JCAHO has designed a Disease-Specific Care in the measured areas. Finally, it requires a review
(DSC) certification to evaluate disease manage- of the effectiveness of the interventions that were
ment and chronic care services. Disease manage- implemented in response to deficiencies that
ment programs not only serve those individuals were identified by the measurement activity. The
suffering from specific chronic illness such as JCAHO-DSC certification indicates that services
asthma but also identify at-risk individuals and provided have the critical elements needed for
work to promote the prevention of chronic ill- long-term success in improving outcomes; more
ness. DSC certification is an approach to chronic importantly, it is a validation of the program’s
condition management that: internal performance improvement initiatives.
In conclusion, the Institute of Medicine 2001
• Supports a participant’s self-management report, “Crossing the Quality Chasm: A New
activities Health System for the 21st Century,” identified
• Utilizes a standard method of delivery with chronic conditions as the leading cause of dis-
integrated and coordinated clinical care based ability, morbidity, and death. Moreover, chronic
conditions account for the majority of healthcare their home but to identify environmental and
expenditures. The report identified six specific other factors that may be harming or somehow
aims for improvement in healthcare, specifically affecting the occupant with asthma.
that the healthcare provided should be safe, effec- A home visit can be a tremendous source of
tive, individual-centered, timely, efficient, and information for the asthma educator. It is an
equitable [62]. The report also included ten sim- opportunity to:
ple principles to achieve improvement:
• See them in their personal (daily) surroundings
1. Care is based on continuous healing • Observe the interactions between family
relationships. members
2. Care should be customized depending on • Inspect the environment for triggers
individual needs and values. • Attain a greater understanding of the family
3. Control should lie with the individual. • Appraise those factors that increase the risk
4. Knowledge and information should be for death from asthma
shared with the individual.
5. Clinical decisions should be A home visit allows the educator to evaluate the
evidence-based. living conditions, to examine the individual’s bed-
6. Safety should be a priority. room, and to assess the impact of the disease on
7. The system should be transparent. the family. Since children generally spend most of
8. The system should anticipate needs rather their time indoors, with a large portion of that time
than react to events. spent in their bedroom, ascertaining the list of
9. The system should not waste resources or the allergens found in the bedroom can be of signifi-
individual’s time. cant help toward modifying the person’s environ-
10. Cooperation among clinicians for informa- ment and achieving control of asthma. Increased
tion and coordination of care is a priority. exposure to indoor allergens has been linked with
increased respiratory morbidity [63, 64].
Evaluation is the cornerstone for improvement The home visit is also an opportunity to pro-
in healthcare, in educating individuals with vide asthma education to the entire family and
asthma and for attempts to improve the current any resident caregivers [65].
health system. It is only through setting standards
and continually evaluating attempts to achieve
and surpass current standards that improvements 16.3.1 Assessing the Environment
can be targeted and sustained.
The initial assessment (for a list of detailed ques-
tions that may be asked, see “Home Assessment”
16.3 Teaching in the Home in Chap. 5) should inspect and assess:
Why offer or carry out home visits? • The home and living conditions.
Home visits can help identify environmental • Whether any member smokes tobacco. The
problems affecting children whose allergy and/or nose will provide information about “a non-
asthma symptoms are persistent and appear not smoking” household.
to respond to medication. They are useful in deal- • Four specific areas—bedroom, living room,
ing with high-risk individuals, such as those who kitchen, and basement—for possible allergens.
have repeated hospitalizations and those who • Possible allergens and irritants due to damp-
appear to be non-adherent. ness, humidity, and heating fuels [66].
The home visit may be viewed as an invasion • The heating and air-conditioning systems.
of personal space; hence its purpose should be • Products used in cleaning clothing and the
stated in advance. The family should be reassured home environment.
that the visit is not to judge the cleanliness of • The cleaning methods or techniques employed.
16.3 Teaching in the Home 585
The educator requires basic equipment in ronment, the teaching can begin. It is essential to
order to perform the required environmental determine the major worries and concerns of the
assessment. Besides a checklist of asthma trig- individual and family and to assuage them before
gers, the following tools are required: any attempts are made at education.
Education needs to be provided in the follow-
• Thermometer to measure indoor temperature, ing areas:
• Hygrometer—these devices are generally
available combined with a temperature gauge Environment—modifications that the family
and measure both indoor temperature and can make without a large financial outlay, listing
indoor humidity. those that should be done immediately and those
• Portable hand vacuum cleaner to obtain dust that can be delayed. Negotiation will be required
samples from different sites—2 square meters so that the family will be willing to undertake
of mattress surface, bedroom floor, family room these changes. Mattresses and pillows need to be
couch, or chair and 1 square meter of carpet and, encased, bedding washed at 130 °F (54 °C), and
in some cases, from stuffed toys, if there is such machine dried. The individual’s bedroom should
a collection in the home, particularly in the have the minimum of furniture, no carpeting, and
child’s bedroom. The dust samples will provide be dusted daily with a damp cloth. Drapes should
information about pet dander, cockroach feces, be replaced with easily cleaned blinds or wash-
and dust mites. Each site has to be vacuumed for able curtains.
2 minutes. The contents of the vacuum filters
should be brushed into small plastic bags (using Heating system filters must be changed on a
a small clean brush each time), labeled, and regular basis, the air-conditioning temperature
stored at −4 °F (−20 °C) in a cooler with dry ice maintained at 75 °F (24 °C) or lower, humidifiers
until they can be sent to a laboratory to be ana- cleaned daily, and, in areas of excessive humid-
lyzed. Other consumable supplies include filters ity, sealants applied to prevent the spread of
for the vacuum cleaner, small brushes, timer, moisture. The use of dehumidifiers should be
plastic bags, labels, gloves, pens, extension cord recommended.
for vacuum cleaner, a tape measure, and a cooler Evidence of a pet requires that the family be
with dry ice. aware of its possible harmful effect on the per-
son with asthma, and since this is a sensitive
All of these items are required for a thorough area, negotiation must be conducted with
environmental assessment. When such an assess- patience and openness. Should the pet be kept
ment is not possible, it should document the fol- outdoors? Will the climate permit this? How
lowing items: can the pet be prevented from entering the indi-
vidual’s bedroom? Who will wash the pet and
• The individual’s past history of asthma how often will this be done? Will family mem-
• Pattern of each acute exacerbation bers remember to wash their hands after touch-
• Warning signs ing the pet? Are they willing to live without the
• Triggers pet as part of their life? Consideration must be
• Symptoms given to the family’s willingness to accept and
• Current management comply with the recommendations. The family
• Level of literacy must be made aware of the health risk associ-
• The impact of asthma on the family ated with noncompliance. Reduction of specific
• The individual and family’s knowledge of allergens will reduce symptoms in the person
asthma and their current attitude toward the with asthma. Consult with the family, and
disease adjust the plans to suit all of them. List items
that require immediate attention and those that
Once the assessment is complete and the edu- can be delayed, keeping in mind the family’s
cator is able to relate the results to the home envi- resources.
Families living in rented accommodation face Before leaving the home, make an appoint-
further challenges in addition to the obvious ment to meet again in about 2 weeks, and leave a
financial ones. Landlords can be particularly dif- card with the clinic name, address, and telephone
ficult to deal with and may be reluctant to spend number so that they can contact the clinic in case
funds on housing that is substandard or to do any- of necessity. After the meeting, document all
thing that requires further cash investment in the details of the visit: medical aspects, family mem-
property. There may be problems with removing bers present, the information discussed, sugges-
the carpet. Dampness and mold, high levels of tions and observations that were made, the
cockroaches, and inadequately ventilated and changes to the asthma plan that were recom-
poorly maintained buildings have a greater mended, and the date of the next visit. Sign the
impact on the health of the person with asthma record with name, date, and time of visit. On
than on people without asthma. In some cases it returning to the clinic, discuss the individual with
may be necessary to contact community resources the asthma team, and plan for the intended
to implement environmental changes. follow-up.
Therapeutic regimen—update or provide the Initial follow-up should be in 2 weeks,
person with an asthma action plan and explain depending on the individual’s needs. A follow-up
how to follow it. If the person is old enough to must be conducted after every exacerbation.
use a peak flow meter, then demonstrate and Every telephone call should be documented and
teach its use. Leave a peak flow meter with the visits to their home or office scheduled according
family after showing them how to care for the to their needs. Since one visit can never ade-
device and how to record readings on the chart quately provide the education required, repeated
provided. If the person is too young to use a peak visits with telephone follow-up and referrals to
flow meter, then provide the parents with a symp- other education resources and support groups
toms diary and explain how the symptoms are to should be part of the planned program.
be recorded. Check that the family understands
what is required of them daily and the purpose of
the diary and how to use it. 16.3.2 The Home Teaching Kit
Devise a short-term plan to take care of imme-
diate concerns and to help control the asthma. It is always a good idea to be prepared for ques-
Give it to the family in writing. Provide any writ- tions, concerns, and teaching opportunities when
ten materials you have that are suitable for making a home visit. A home teaching kit should
answering their concerns or to give them more hence include the following items:
information pertaining to their requests.
Ensure that the family has the resources to • Printed material at various literacy levels that
purchase medication and know how the medica- explain what asthma is and its effect on the
tion works, the time to effectiveness, and its pur- lungs
pose. For those who cannot afford the medication, • Visual aids (a small model or charts) that show
suggest financial help from various organizations what asthma does to the lungs
or samples from pharmaceutical companies (see • Action plans that are based on symptoms,
Chap. 11). peak flow zones, or both
Review use of the prescribed device. Ensure • Peak flow meters together with disposable
that the person with asthma knows how to use it, mouthpieces for demonstration purposes
care for it, and where it should be stored. Provide • Completed sample peak flow diaries that show
education to all caregivers, and if the child is of what happens to peak flows when there is
school going age, schedule an explanatory meet- exposure to an allergen and to a viral
ing with school officials, as it will be necessary. infection
Such consultations make you an advocate on • Pens and paper, or a digital device (laptop
behalf of the child and the family. computer, tablet) for note-taking
• Placebo medication devices for teaching how to school staff

to use the prescribed delivery system • Be an advocate for staff members or students
• Spacer to be used with placebo MDIs for dem- with asthma
onstration purposes • Perform a classroom environmental
• Green and yellow stickers so that medication assessment
can be marked for “regular” use and “emer-
gency” use (especially helpful for immigrants The first three items should pose no difficult to
and persons with low literacy) the educator. The last one—the classroom envi-
• Printed leaflets on a variety of topics such as ronmental assessment—is discussed in some
keeping a room dust free, an explanation of detail below.
allergy, use of a peak flow meter, etc. and/or a
list of websites where reliable information is
readily available 16.4.1 Classroom Assessment
• Appropriate record-keeping forms that cap-
ture both medical data and teaching provided Most educators will not be technically qualified
• Information on how to stop smoking to precisely evaluate air quality, mold, and pollut-
• A checklist of asthma triggers, to be used as a ant levels within the classroom. Any assessment
reminder when discussing triggers with the will hence highlight only those deficiencies that
person and their family are immediately obvious to the educator but have
• Samples of masks that can be used to decrease possibly been overlooked by school staff. These
allergen exposure deficiencies may need further investigation by
• A list of local support and community groups qualified professionals.
• Business cards on which the educator’s first The performance of an environmental assess-
name is written ment of a classroom entails visiting the
classroom(s) and listing possible allergens to be
It is generally not advisable to provide the found there. However, an inspection of the class-
educator’s last name or personal phone number. room alone will not be enough. The classroom is
However, they should be told where to go for part of the school, and the school is part of a
help on holidays and weekends. neighborhood. The educator should hence also
The above list should be used as a starting quickly review the school, the neighborhood
point, and items can be added or deleted from it around the school, and the school’s policies per-
as the educator gains experience with the particu- taining to children with asthma.
lar area that is served by the clinic. Every item Inside the classroom, the following are of
that is used should be recorded in a list, and the concern:
list kept up to date so that a different educator
will know what was deemed essential for a home • Perfumed or scented products worn by teach-
visit in that particular locality. ers and students.
• Scented products used in the classroom (mark-
ers, stickers, etc.).
16.4 The School Environment • Open shelves [67].
• Furnishings and textiles in the classroom (res-
While the school nurse may be the major day-to- ervoirs of irritants and allergens) [68].
day source of information at school, on occasion • Chalk dust, plants, mold, cockroach allergen,
the asthma educator may be requested to: and tobacco smoke [69].
• Room deodorizers, art supplies, oil-based fin-
• Make a presentation to either staff or students ger paints, rubber cement, and potpourri.
about asthma, allergies, and/or anaphylaxis • Pets in the classroom.
• Help a parent communicate the child’s status • Presence of carpeting in the classroom.
• Recent repairs or renovations. • What chemicals are used for pest control and
• Dampness that is a risk factor for cough, where are they stored?
wheeze, and asthma [70, 71]. • Are all food-related areas free of cockroach
• Defective air-condition or heating system allergen? [72]
(HVAC).
• New carpeting that is “off-gassing” (source of Other indoor items of concern include:
formaldehyde and other noxious chemicals
that include fire retardants, pesticides, and • Air humidity levels above average
dirt-repellent coatings). • Above average levels of formaldehyde and
• Inadequate air circulation. Fluctuations in other volatile organic compounds
temperature from room to room indicate poor • Lower or fluctuating room temperatures
air circulation. • Viable molds or bacteria
• Cat and mouse/rat allergen
16.4.2 Within the School Cat allergen is ubiquitous. It sticks to clothing

and is brought into the school on the clothing of
Air quality inside the school is affected by the students and staff who have cats at home, thereby
chemical composition of construction materials, facilitating exposure for those who do not have
furnishings, food services, methods of cleaning cats. For the child who has problems with cat
and maintenance, pest control, classroom activi- allergen, the simplest solution would be to sur-
ties, and the people in the school. Thus, the fol- round that child in the classroom with other chil-
lowing questions should be asked about the dren who do not have cats.
school: Allergy and asthma symptoms can be exacer-
bated by the quality of the indoor school environ-
• Has the school’s indoor air quality been tested ment [73] and the air outside.
recently?
• Does the air meet national standards?
• Are air ducts cleaned regularly? 16.4.3 Outside the School
• Are filters in the ventilation system changed
regularly? A quick look outdoors may prove revealing.
• Are the ventilation systems, humidifiers, air Nearby new construction adds dust and pollu-
conditioners, and furnaces serviced regularly tion to the air. So do highways, busy roads, and
and measures taken to ensure that they are factories, both old and new. Even the new so-
mold-free? called “high-tech” facilities, while they appear
• Are air outlets clean in appearance, or do they innocuous and clean, will discharge pollutants
appear grimy and sooty? into the air that can affect people in the sur-
• Is the school free of tobacco smoke at all rounding area. All these contaminants will
times? enter the school through doors, windows, and
• Has the air been tested for radon? the HVAC system.
• Has the water been tested for lead? Questions should also be asked about the
• Are art room supplies water-based rather than school grounds and the location of garbage cans.
oil-based? Allergic reactions to hymenoptera (bees, wasps,
• Does the science room have an adequate and hornets) can be avoided if garbage is kept in well-
separate exhaust system? sealed containers away from play and sports
• Do all cooking areas have a separate exhaust areas. The asthma educator should also inquire as
system? to whether any road or house repairs are being
• Are cleaning chemicals stored safely in a done or if asphalt is being laid in the school
well-ventilated area? grounds or neighborhood.
Together, the information elicited should pro- • Are students with asthma permitted to pre-
vide basic data for an initial environmental medicate prior to a gym or physical education
assessment of the school environment. class and to take medication as required dur-
ing physical education activities?
• How does a teacher inform the office if a stu-
16.4.4 School Policies dent falls ill? Since the class cannot be left
unsupervised, who accompanies the ill student
Policies that affect students with asthma should and where is the student taken? Who then is in
be clarified in discussions with school adminis- charge of a student who falls ill?
trators and staff prior to the student being • Does the school have a contingency plan for
enrolled. Consider the various items listed below. moving students to a safe environment to pro-
tect them from unexpected renovations, paint-
• What is the school’s policy pertaining to ing, or air quality problems?
medication? Are responsible students per- • Have the entire school staff (administrative,
mitted to carry their asthma medication with teaching, support, janitorial, and bus drivers)
them at all times? Is there ready access to had a refresher course on asthma and aller-
medication for children not able to handle gies? The course should be repeated regularly
their own medications? Or is the medication for new staff members and because teachers,
locked in an office and unavailable when the like everyone else, tend to forget if material is
occupant is away? not reviewed.
• What is the school’s policy pertaining to stu- • What is the school’s policy on tobacco? On
dents with asthma in physical education vaping?
classes or sports activities? What allowances • Is every parent/guardian asked whether the child
are made for these students? How well has asthma and/or allergies? If the answer is yes,
informed are athletics and play supervisors are they required to complete an emergency data
about asthma? form that identifies the students, medications,
• Are students allowed to take their medications how to identify an emergency and what mea-
on both short and long field trips? sures are to be taken, healthcare provider, and
• Are students with asthma allowed extra time where a responsible adult can be reached at all
to complete missed schoolwork? If a student times? Is a copy of this form kept both in the
has an asthma exacerbation that results in a office and in the student’s homeroom? Is the stu-
number of missed days, what measures are dent’s photograph on the form for quick and
available to help the student catch up on the easy identification? Are all teachers informed of
missed work? the student’s medical status? These forms can be
• Does the school have a written asthma/allergy obtained from www.aafa.org.
policy? The policy should describe the role • Parents and the asthma educator should
specific school personnel should follow dur- inquire as to whether the staff has been trained
ing an asthma exacerbation or allergic reac- to handle an asthma/allergy exacerbation.
tion. It should identify by name (or title) those Have students been told what they can do to
persons who will: help a student who is having an asthma attack?
–– Be in overall charge of (that is, manage) the Do health courses include units on both
event asthma and allergies? Who teaches these
–– Phone the parents units? How are substitute teachers informed
–– Monitor the students both before and after about the medical needs of the students they
they have taken their reliever medication will be teaching?
–– Stay with the student during an asthma/
allergy episode A final question could deal with an asthma
–– Call for the ambulance drill. Just as students are taught what to do in a
fire drill, the school staff could do a practice of an student(s) having an asthma attack [74], but it
asthma or anaphylaxis emergency. Has the school could just as easily be some other staff member.
ever done this? A rehearsal of such a procedure Hence there is a need to educate not just the
will clearly indicate omissions and, above all, teaching staff but all school personnel,
will provide the school staff with the confidence including:
that is required to deal with any emergency.
Teachers are concerned about students with aller- • Members of both the administrative and sup-
gies and asthma. A study by Atchison and Cuskelly port staff
evaluated teachers’ knowledge about asthma. • The janitorial staff
Teachers with asthma tended to be more knowledge- • All school bus drivers
able about the disease than teachers without asthma.
However, 93% of teachers indicated that they wanted It is essential that the education provided meet
more information on asthma [67]. the needs of these nonmedical personnel. It
should also be extended to volunteers who work
in any part of the school. All adults in authority
16.4.5 Physical Education should know how to handle an asthma attack.
Five to ten percent of US students in the school
All teachers involved in physical education pro- system (from elementary to high school) have
grams, coaches, and volunteer helpers must be asthma. Each student has, on average, 12.5 days
informed of a student’s asthma and/or allergies. of restricted activity, 7.6 days of absenteeism,
They must be made aware that asthma will differ and an increased risk of both perceived poor
from student to student and from moment to health and learning disability [75]. Certain ethnic
moment in each student. Asthma is, after all, a groups have a greater risk of asthma absences.
variable disease. Thus, activities performed eas- For instance, in California, African American
ily at one time may be increasingly difficult elementary school boys, at 9.4 days average
shortly thereafter. The student may not look ill missed primary school days, have the highest
but exposure to irritants and allergens will affect absenteeism among racial and ethnic groups [76].
lung function and reduce their ability to partici- Another study found that asthma was related to
pate fully in various activities. between 14% and 18% of student absenteeism
It is essential that a student who admits to hav- [77]. Hence the school is one more location
ing difficulty with asthma be believed. Parents where asthma education can and should take
and older students can avoid many of the inherent place.
difficulties that beset the student with asthma by Asthma education has been successfully pro-
invoking the aid of their healthcare provider. An vided in schools. A study of school nurses found
asthma action plan with peak flows, and signed that a preliminary session with an individual stu-
by the healthcare provider, will be helpful. If it dent was helpful in engaging interest and encour-
indicates the level of peak flow that points to aging participation in follow-up group sessions
problems with the asthma, it will provide teach- [75].
ers with an objective measure to ensure that the The asthma educator will be seen as an addi-
student is not trying to avoid responsibilities in tional resource by teachers who are not too famil-
schoolwork and assignments. iar with asthma or who are concerned about
anaphylactic students in their charge. A talk given
in a school requires a “show and tell” approach
16.4.6 G
eneral Education for School that has to be adjusted to the level of the students
Staff or staff. For students, a talk followed by a suitable
video presentation (adjusted to their grade level)
Many schools have school nurses, and some have will help hold their interest. Note that the presenta-
part-time nurses. Often, the school administrative tion to students will not be suitable for teachers
assistant will be responsible for the care of since the concerns of both audiences are very
different and that a presentation that focuses on the about the nature of their child’s asthma and aller-
problems of the target audience is more acceptable gies. Parents should meet school authorities
than one that is couched in general terms. (administrators and teachers) to discuss the
The NHLBI offers a 2-page downloadable pdf child’s needs and the ways in which the child’s
titled “How Asthma-Friendly Is Your School?” diseases can be handled in the school. They
with the second page listing resources for fami- should take with them the child’s medications list
lies and school staff [78]. A copy of this would be and information about epinephrine injectors if
useful when making a school presentation. necessary, environmental safeguards, guidelines
In making a presentation to school staff, it is for exercising, and emergency protocols. The
advisable to take a copy of some of the booklets school’s policy about medications and their usage
from NHLBI to leave with the staff. They include: should be carefully explored. If the policy is
restrictive or nonsupportive, parents may contact
• How Asthma Friendly is Your School? the US Department of Education Office for Civil
• Asthma and Physical Activity in the School Rights.
[79]
• Managing Asthma: A Guide for Schools [80]
16.5 Evaluation of Education
Managing Asthma: A Guide for Schools also Programs
has a student asthma action card which can be
used to create an individualized health plan for a Within any asthma clinic, there is always room
student. It also provides guidelines for adminis- for improvement. All plans need to be evaluated
trators, teachers, coaches, and students. The regularly so that weak areas may be strengthened
NHLBI also offers a six-lesson course on asthma and good areas made better. There is always room
management that was created for the Latin-x for improvement. Asthma education is particu-
community. It provides culturally appropriate larly well suited to evaluation since the outcomes
teaching scripts, handouts, and activities [81]. in terms of the disease can be easily recognized
The American Lung Association website has a and measured. In earlier years, it was difficult to
long list of resources for educators and individu- demonstrate that education affects the course of
als with asthma. asthma, but it is becoming easier to do so as more
Educators should take samples (asthma medi- studies are completed on the effect of education
cation devices, peak flow meters, placebo epi- on outcomes [1, 2]. The prevalence of asthma is
nephrine injectors, etc.) with them when invited such that every practice will have a large enough
to speak at a school. These provide actual mate- number of these individuals in order to be able to
rial for the audience to touch and inspect, as well carry out meaningful evaluations of the quality of
as add interest to the talk. A model and/or chart of the education.
the lungs and the respiratory system will also be Asthma specialists have long focused on pre-
helpful. ventive drug therapy and environmental control.
Providing asthma education to teachers and Now these ideas have influenced the general
students is effective. A study involving an ele- medical community, and the treatment of asthma
mentary curriculum that integrated asthma edu- has changed dramatically in the last 10 years. For
cation found that it was beneficial not only for the example, emphasis in drug treatment has moved
teachers and children with asthma but it explained from short-term symptomatic treatment to long-
asthma to the children without asthma and laid term treatment intended to control inflammation.
the foundation for health literacy [82]. There has been a renewed interest and emphasis
on identification and avoidance of allergens. It is
16.4.6.1 Parents and School likely that treatment techniques and methods will
The asthma educator must remind parents of pre- continue to change and evolve. The clinic will be
school and elementary children that it is their the ideal ground for implementing and evaluating
responsibility to notify the authorities in writing such changes, and this same evaluation can help
define and clarify areas of concern, whether should highlight those areas where performance
administrative or clinical. is adequate or excellent and those that need
The purpose of evaluation is six-fold. It: help. In planning an evaluation, two things
must be considered. First, the purpose of the
• Measures effectiveness evaluation has to be defined. In other words, its
• Identifies areas of weakness focus and parameters must be clearly delin-
• Clarifies objectives eated. This will determine the scope of the eval-
• Justifies allocation of scarce dollars and uation program and provide an assessment of
increasingly limited resources the resources available. Secondly, the criteria
• Demonstrates accountability and tools for evaluation have to be specified.
• Promotes the spread of good educational Methods and techniques have to be formulated
materials and instruments for gathering data have to be
selected. The program should:
Evaluation requires good data. Systematic
data collection should hence be a major compo- • Identify problem and problem-free areas
nent of the planning process, rather than an after- • Increase opportunities for teamwork
thought. It has to be part of the initial planning • Help develop expertise where it is lacking
for program development. It requires careful • Redefine responsibilities as necessary
development, energy, and determination, but the • Reveal the deficiencies in facilities
results can clearly demonstrate whether the target • Enhance future record keeping
objectives were achieved. • Provide guidelines for a more consistent
Evaluation serves different purposes. It articu- approach to treatment
lates the objectives to be attained through the
education programs, defines the purpose of the An evaluation program can be started at any
program, and specifies the expected outcomes. time. Since the asthma educator and healthcare
Above all, it can indicate whether the teaching provider(s) will design the program, it can obvi-
done within the clinic is effective or not. It is also ously be comprehensive or specific, general or
a tool for self-evaluation. detailed, and designed to measure as much or as
The five-step approach to evaluating the edu- little as desired. Herein lies the conundrum.
cational programs at a clinic comprises: Evaluation demands both time and effort, and it
makes sense to do as careful and as thorough a
• Designing an evaluation program job as possible, so that good, meaningful results
• Establishing standards and objectives are obtained. At the same time, however, the eval-
• Collecting and organizing the data uation process will increase employee workload.
• Data analysis Additionally, the more data collected, the more
• Review time-consuming the data analysis will become.
The most difficult challenge, when designing
Each of these is now considered in detail the evaluation program, will be to create a pro-
below. cess that is reasonable for the size and financial
strength of the clinic. The program must give the
best possible return on the investment of time,
16.5.1 Designing an Evaluation money, and brainpower. The first attempt should
Program be modest in scope, small in size, and short in
duration and measure just a few indicators of effi-
Put briefly, any evaluation program should ciency. A small program will form an excellent
clearly indicate the current status, identify areas starting point and also provide the necessary con-
of success in providing a good service, and fidence to undertake a more ambitious evaluation
indicate areas that require improvement. It program.
Ideally, the team that designs the evaluation In effect, evaluation of outcomes includes
program should include the asthma educator, the clinical, functional, and financial elements as
healthcare provider, other persons at the facility well as individual and family satisfaction. When
who work with individuals with asthma, a person evaluating the clinic, almost any aspect of opera-
with experience in statistics or surveys, and pos- tion or result can be reviewed [3]. If the overall
sibly a computer systems analyst who can set up economic benefit of the clinic is the objective,
the data collection process or design the neces- then many items have to be considered. For any
sary reports. Individuals with asthma must be evaluation, all costs will have to be considered.
part of the process. There will be costs associated with personnel,
What can be evaluated? Should it include equipment, printed materials, resource materials,
the overall effectiveness of the program or the and facility costs. There will be process-related
increase in the ability of individuals to manage costs such as program development, administra-
their asthma with minimal help from profes- tive costs, secretarial and managerial costs, and
sionals? Or should it evaluate the teaching many others.
method, delivery, design, or length of each There are many approaches or methods for
educational session? How does one determine evaluating costs. One method is a cost/benefit
if a program is being successful? Does one analysis and another common one is a cost/effec-
measure the process or the outcomes? If one of tiveness analysis [83]. The former is based on
the more limited objectives is chosen, which evaluating the results of healthcare intervention
one should be chosen? A little thought will (i.e., education) in individuals with asthma by
lead to the rapid conclusion that there are many comparing the results of the same intervention in
variables here, each of which can be measured those who did not receive any education. Here the
and evaluated. technique used to determine if a program is worth
There are many different ways of measuring the money invested in it requires that the benefits
the many variables. In short, one could easily find and costs be quantified and expressed as a ratio.
oneself collecting the wrong type of data and Thus, if Program 1 costs $1000 and gives a benefit
having to start all over again after a few months of $150,000, then its cost/benefit ratio is:
of wasted effort. In general, while it is attractive
to think that the overall effectiveness can be eval- 150,000: 1000 which reduces to 150:1
uated, it is usually better to start with simpler
outcomes. while if Program 2 costs $1500 but produces a
It is hence vital that the areas to be evaluated benefit of $195,000, then its cost/benefit ratio is:
are first carefully defined, following which the
necessary data items that will help develop that 195,000:1500 which reduces to 130:1
evaluation are selected. Some examples are pro-
vided for consideration. In terms of progress or This clearly indicates that Program 1 is better
improvement as a result of educational activities, for it gives more benefit per dollar of cost (150 is
there are essentially six categories that can be greater than 130).
measured. These include changes experienced by This analysis does not consider variables such
the individual with asthma in: as quality of life, reduction of anxiety, prevention
of exacerbations, and so on. It can only look at
• Feelings and sense of emotional well-being, quantitative outcomes. It is even more time-
quality of life consuming and expensive to do a cost/benefit
• Knowledge and attitude toward asthma analysis that would measure the economic impact
• Reduction in symptoms of such interventions. Thus, a cost-effectiveness
• Lung function evaluation is far more practical since the out-
• Activities pertaining to daily living comes are specified and costs are attached to
• Use of medical resources these outcomes.
A cost-effectiveness evaluation has two In measuring symptoms, the frequency, inten-

requirements: sity, and duration should be a consideration. A
scale (ranging from 1 to 10) could be used to
• A measure of comparative effectiveness evaluate symptoms, with symptom-free days
• An estimate of all costs constituting a goal of management. The physio-
logical and healthcare utilization outcomes tend
In evaluating two different programs, the total to be the most objective but are also prone to
cost of running the programs is calculated. The error. For instance, the healthcare utilization rate
costs are then allocated per individual. can be clouded by the inability to differentiate
Thus, for example, if Program 1 costs $1600 between poorly controlled asthma and severe
for ten individuals, that means it cost $160 per asthma. In attempting to influence costs, how-
person. If the person made four visits, then the ever, it makes little difference why someone has
cost per visit is $40. many emergency department visits or hospital
However, if Program 2 costs $1800 for 12 peo- admissions. The important thing to recognize is
ple or $150 per person for 3 visits, the cost per visit that education can positively influence their
is $50. Program 2 is not as cost-effective as behavior whatever the underlying reason. For
Program 1. Here the program with the lower cost example, increased bronchodilator use may be
would be considered optimal. Note that in this the result of reduced intake of inhaled steroids,
example the data is compared in different ways, as yet in an adherent person, it could be an indicator
in the cost per person visit and cost per of increasing severity. In both cases there will be
individual. more visits to the emergency department.
Table 16.1, which is in no way comprehen- While there are a number of statistical mea-
sive, lists six areas on which the evaluation can sures to consider for collection and use, the fol-
be focused and the results or outcomes that can lowing forms a good starting point:
be measured. It is worth noting that much of the
data necessarily relies on the memory and hon- • The percentage of individuals in the practice
esty of the individual reporting the data. This who have asthma
may be considered a weakness unless there is • The percentage of them on inhaled
some method of verification that can be employed. corticosteroids
An assessment of asthma management should • The percentage of those hospitalized in the
be based on behavior. It should include both pre- last time period (any specified period of
vention and attack management strategies. The time)
NAEPP guidelines list possible measures. Part of • The number who went to the emergency
management behaviors could include the skill set department in the same time period
involving communication and negotiation, both
within and without the family [84–86]. Table 16.1 presents a list of possible out-
Where possible, direct observation should be comes that can be measured in areas such as
used to verify behavior. All behavioral data must physiology, symptoms, treatment, self-manage-
be considered in terms of outcomes such as ment, use of medication, and healthcare utiliza-
symptom control, functional status, treatment tion. Care should be taken with self-reported
side effects, and healthcare utilization. These in outcomes such as diary cards. Individuals have
turn should be correlated with the attitudes, been known to complete these cards just prior
beliefs, and feelings of the individuals involved. to an appointment so that many of the related
Thus, the link with predisposing factors will readings are both falsified and a tribute to their
enable the educator and the asthma team to better imagination. Suspect readings or notations in a
understand the individuals with asthma and diary should then yield to direct observation of
devise those methods most appropriate to aid in symptoms and to other means which can be
changing behavior [87]. more readily validated.
Table 16.1 List of outcomes that can be measured 16.5.2 Establishing Standards
Areas Outcomes
Physiological Peak flow Once outcomes have been chosen and objectives
FVC defined, it is essential to establish some criteria
FEV1 pre- and post-beta 2
Clinic and Diary card
for measurement. This will allow measurement
symptoms Waking at night of the outcomes against some standard or target
Cough that is desired.
Wheezing For the first evaluation exercise, a strong rec-
Dyspnea
Chest tightness
ommendation would be to select modest targets
Sputum production that can easily be achieved. With each successive
Treatment Side effects evaluation however, the standard or target should
Medication categories be raised. The evaluation should be seen as a con-
Use of inhaled/oral steroids
tinuous process for improving the asthma clinic.
Self-management Action plan
Attack management For example, it is known that 10–15% of chil-
Maintaining peak flows dren and 5% of adults have asthma. Keeping
Methods of monitoring these figures in mind, it should follow that in any
Attendance at school/work family medicine or pediatric practice (assuming
Ability to do daily tasks
Exercise regularly that a practice has only one asthma clinic) at least
Use of Medication usage 10% of the children will likely be diagnosed with
medication Technique asthma as will 5% of adult. This however may
Adherence not be the case at a clinic because of inaccurate
Healthcare Hospital admissions
diagnoses, inaccurate histories recorded from the
utilization Emergency department or urgent
walk-in clinic visits individual’s memory, incomplete records from
Mortality individuals being transferred, and so on. Hence,
it may be desirable to find out if the clinic follows
the general trend. Do 15% of the clinic’s adults
have asthma? If not, does this mean that a num-
The clinic may wish to be more specific and ber of individuals are not being diagnosed?
maintain counts for the number of individuals Here are some possible targets that may be
who: considered, for any time period that is selected
for the evaluation study:
• Use a peak flow meter and record their PEF
• Have proper inhaler technique • 50% of individuals with asthma who measure
• Have reduced the number of “sick” days off peak expiratory flows should be at their per-
from work or school sonal best readings.
• No longer have trouble sleeping at night • 50% of individuals with asthma should be on
• Exercise regularly without any asthma symp- inhaled steroids. This can later be increased to
toms developing 70% or even 80% of individuals with asthma.
• 80% of those with asthma should be able to sleep
Whatever outcomes are desired can be mea- through the night without waking due to asthma.
sured within the asthma clinic database. These • Individuals should have reduced their visits to
outcomes or objectives must be measurable and urgent walk-in clinics or emergency depart-
quantifiable. They should not include the level of ments by 50% when compared to a previous
satisfaction or how they feel about the education time period.
program. Education requires changes in behav- • Individuals should have reduced their hospital
ior, and it is these changes that should be identi- admissions by 25% when compared to a pre-
fied and measured. vious time period.
• Individuals should have reduced their number After a decision has been made as to what
of sick days away from work or school by should be measured, there will be a need to exam-
25% when compared to a previous time ine the ways in which the necessary raw data can
period. be collected, stored, and organized. All the data
required should be present in the files of all indi-
The objectives or targets must be documented viduals with asthma.
in writing as clearly and as unambiguously as
possible. The asthma educator and the team Data collection Data may already have been
involved in the evaluation should review them recorded within the clinic’s computer system, or
regularly, instead of relying on memory. A clear handwritten notes may have to be reviewed in
set of written goals will make analysis and evalu- order to get this data. The method of collection of
ation much easier, and these must form part of data will depend to a large extent on the equip-
the written records for the clinic. The standards ment available within the practice. A computer
set must require individual involvement as a will simplify the task as will any of the available
major factor in the education process. computer programs (Palm Asthma, HealthEngage,
etc.) that are specifically designed for asthma
clinics.
16.5.3 Data Collection
Dress rehearsal Before the actual data collec-
Data can be both quantitative and qualitative. tion project is begun, it may be worthwhile to
Quantitative data is specific. It can be enumer- hold a “dress rehearsal” or dry run. This will
ated and a value assigned to each category. highlight any problems inherent in the plans for
Examples would include the number of hospital the collection method, or the forms to be used, or
admissions, the number of prescriptions for a the way in which data will be compiled for analy-
given drug, the number of emergency visits, the sis. The rehearsal must be done with a representa-
number of days lost due to asthma, etc. tive sample of data—too small a sample may
Qualitative data is much more difficult to quan- invalidate the exercise.
tify—to list or have a value assigned to it. It
generally involves descriptive terms used in Responsibilities The responsibilities of each
evaluating education programs, experiences person collecting the data must be clearly defined
listed in a diary or logbook, or interviews and in advance of the evaluation. Different staff mem-
also includes things of a descriptive nature that bers may be responsible for different areas, and
cannot be transformed into numbers and easily these diverse activities should be coordinated.
manipulated. Clear directions as to who is responsible for par-
Some qualitative data can be quantified by ticular areas are essential.
assigning a value to information. For instance,
asking an individual with asthma to describe on a Time A time frame that is most convenient for
scale of 1–5 how they feel about something the clinic should be set. Some clinics do an evalu-
(whether quality of life or the degree of discom- ation every 6 months, others yearly. Any time
fort associated with symptoms - where 1 could period can be set and the data collected at the
indicate that they have no symptoms while 5 beginning and at the end of that same time period.
could represent a level of symptoms that pre- This can even be done retroactively.
cludes normal activity) is one way to quantify
subjective data. Most quality of life scores do this
with different scales. Some use a three-tier scale 16.5.4 Data Analysis and Evaluation
of unsatisfactory, satisfactory, and excellent with
a numerical value assigned to each descriptive Once the data has been collected, it must be ana-
category. (See Fig. 1.1 for quality of life scores.) lyzed. The analysis should permit comparison of
actual performance against the agreed standards Identification of problem areas is useful in
or the initial objectives. This will then help iden- designing intervention strategies. It should be
tify those areas within the clinic that require remembered that inability to achieve the targets
improvement. or objectives is not necessarily a bad thing, nor an
Analysis of the data could point to problems indication of failure. It could mean that the tar-
in one, two, or all of the three areas: provider gets were set too high; it could also result from
behavior, system design behavior, or the behavior attempting to achieve too much in a very short
of the individual with asthma. From the perspec- period of time.
tive of provider behavior, the team must review Each “failure” must be carefully analyzed
any lack of knowledge and skills of the team before any conclusions are drawn from it.
members, followed by a clear examination of the Likewise, any outstanding successes achieved
team’s commitment to the initial standards. Were should also be similarly scrutinized. Were they
all members committed to providing the same so successful because of overly modest targets?
quality of education? Were all members working Were the wrong things measured? Was individ-
together and providing a team overview of the ual behavior an integral component that linked
individual? educational criteria with the usual medical cri-
The educational methods must be evaluated— teria? Was the documentation inadequate? A
do they need to be changed? Is sufficient time conservative approach to the interpretation of
spent with each individual? Is too much informa- the results obtained will make the results more
tion being provided at one time? Is the literacy credible.
level appropriate? Whatever the reasons, it is Evaluation should determine the degree to
important to identify them, because change can- which objectives were attained, including both
not take place unless what needs to be changed is the intended objectives and also any possible
known. Evaluation should include communica- unintended effects. The latter may be either ben-
tion skills, teaching materials, costs, and format. eficial and desirable or detrimental, but these too
Any changes to be implemented must be done should be monitored.
only on the joint decision of the team.
There may be problems in the way the infor-
mation is collected if the forms are not clear and 16.5.5 Review
unambiguous. Were the forms simple enough to
use through the whole, designated period? Did Evaluation process must be a continuous process,
they require an interval of adjustment or did they realistic, and honest if it is to measure the effec-
expand the initial objectives to include so many tiveness of the asthma education program, and
other things that a clear result could not be the findings should immediately be used to incor-
obtained? The results of data analysis may be porate modifications and improvements. The
presented either as percentages or as actual num- plan should be evaluated and updated regularly.
bers. They can then be charted as bar graphs or At the end of the time period designated for the
line graphs that clearly indicate the time period implementation of the plan, the need will arise to
represented. perform yet another evaluation and appraisal to
Consider the outcomes from the viewpoints of see if the new team objectives have been met. See
not only the clinic but also the individual. Look at Fig. 16.6.
all of them. Perhaps they: The purpose of an evaluation is to improve the
healthcare that is provided to individuals with
• Are using an incorrect inhaler technique asthma [88]. There is constant need for assess-
• Have problems with adherence ment and adjustment of the current plan to meet
• Are reluctant to use controllers constantly improved criteria, and this, in turn,
• Are over reliant on relievers requires further implementation. The final result
• Have insufficient follow-up should, ideally, have every person with asthma in
• Information on rates of outpatient referral and

admissions to hospital
• A list of the agreed strategies for coping with
individuals at risk of developing severe asthma
attacks or who show those features which are
recognized associations with asthma deaths
The National Quality Forum (NQF) provides

consensus statements for specific standards to
measure healthcare quality [94]. These standards,
provided by The Joint Commission and other
agencies, are used to measure performance and
strengthen chronic care management. The 11
asthma-specific standards quoted here include:
Fig. 16.6 Iterative improvement • Asthma admission rate (pediatric)

• Asthma admission rate in younger adults
a well-controlled, self-managed asthma program. • Suboptimal asthma control and absence of
The goal of asthma care providers should be to: controller therapy
• Pharmacologic therapy for persistent asthma
• Prevent asthma attacks • Relievers for inpatient asthma
• Reduce morbidity associated with asthma • Systemic corticosteroids for inpatient asthma
• Reduce mortality resulting from asthma • Proportion of patients with a chronic condi-
• Minimize adverse side effects from tion that have a potentially avoidable compli-
medications cation during a calendar year
• Asthma medication ratio
The assessment of healthcare systems from • Relative resource use for people with asthma
US and international organizations such as the • Medication management for people with
National Committee for Clinical Laboratory asthma
Standards (NCCLS), the International • Use of appropriate medications for people
Organization for Standardization (ISO), the with asthma
American Society for Quality (ASQ), to the
World Health Organization’s Health Systems The last four items are measures that are
Performance (HSP) [89–92], as opposed to the required by the Healthcare Effectiveness Data
assessment of the errors of individual practitio- and Information Set (HEDIS) that allows com-
ners, is no longer a relatively new science. Some parison between different health plans.
advances have occurred in countries with a lesser Thus, a healthcare audit is not merely an exer-
focus on individual practitioners or organizations cise to show the effectiveness of the educator’s
than the USA. For example, the British Thoracic efforts. Its purpose is to critically analyze the
Guidelines [93] requirements for a general prac- quality of medical care, from diagnosis and treat-
tice audit include: ment to the effects or outcomes of the educational
programs. It is an extremely effective tool for:
• A registry of everyone with asthma
• A method to determine the frequency with • Analyzing areas of weakness
which individuals with asthma attend the • Defining areas of strength
clinic • Analyzing the use of resources
• Information on the prescribing of both con- • Building a team
troller and reliever medications • Improving team work
16.6 Self-Evaluation 599
• Clarifying job descriptions 16.6 Self-Evaluation

• Providing feedback and job satisfaction
• Improving care of the individual with asthma The educator must constantly review both per-
• Increasing awareness of asthma sonal communication skills and teaching style.
They must become good teachers. Many good
An audit can only be effective if it includes teachers develop the knack of being able to imag-
self-assessment. The latter is an integral compo- ine that they are sitting in the audience and
nent and must be taken seriously. watching themselves: they observe their own
mannerisms, speech patterns, and other “pecu-
liarities,” and they identify those areas where
16.5.6 Confidentiality they need to improve.
Very few people are naturally good teachers.
All health records are confidential, and appropri- They become good through practice—by con-
ate safeguards must be taken to ensure that the stantly observing themselves, by getting rid of
data collected remains confidential and is never their bad habits, and honing their good ones.
released without the appropriate legal permis- Good teachers always review each teaching
sions and consents. To reinforce this point, session, no matter what its outcome. For asthma
HIPAA, the Health Insurance Portability and educators, success is achieved when their teach-
Accountability Act of 1996, imposes strict pri- ing causes positive changes in the individual’s
vacy rules, as outlined below. behavior where, in time, the person with asthma
The analysis of data from the evaluation, takes control of, and eventually manages, the
whether percentages or numbers, may be pub- asthma with minimum outside help. Lack of suc-
licly released, but names or personal information cess is seen when they do not respond to any
of individuals may not. Neither may details that efforts, remain non-adherent, and do not change
would allow a particular person or group of indi- behavior. In either case a good asthma educator
viduals to be identified. In all respects their pri- should review and analyze:
vacy must be preserved and confidentiality
maintained. In other words, anonymity by itself • The results
is not enough, and measures must be taken to • The teaching techniques and approaches used
ensure that there are no clues in the “anonymous” • Personal performance
data that would reveal an individual’s identity.
The 1996 Health Insurance Portability and Ask the following questions:
Accountability Act (HIPAA) [95] with the
Privacy Rule (published August 2002) requires • What worked?
safeguards both in personnel and equipment to • Why did it work?
ensure that there is no unauthorized access or • Could it have been improved even more?
release of an individual’s health information. • What did not work?
Each person who maintains, processes, or trans- • Why did it not work?
mits health information is responsible to ensure • What could have been done to correct the
its integrity and confidentiality, to protect against problem in mid-session?
reasonably anticipated hazards to security, and to • What could be done differently next time?
safeguard against unauthorized uses or disclo- • Were the individual’s needs understood?
sures of the information. HIPAA prescribes very • Were those needs met?
stiff penalties for any person or organization that • Were answers and reassurance to worries and
violates confidentiality. Penalties range from a concerns provided?
fine of up to $50,000 and imprisonment of 1 year • Did personal emotions/reactions affect the
and to $250,000 and up to 10 years imprisonment teaching?
for a criminal penalty. • Was attentiveness shown and nonverbal
encouragement provided? • The use of a variety of communication

• Were the individual and their family involved techniques
in defining goals? • Whether those being taught were actually
• Was the individual’s family sufficiently involved? practicing what had been taught
• Was sufficient consideration given to their • Whether tracking was done of the informa-
environment? tion/education provided to date and what
• Was the assessment current? should be provided in the future
• Are there new problems /stresses that make
adherence difficult? The scale is a brief but effective checklist and
• Was their right to change their mind recog- can be used by asthma educators for a quick
nized and accepted? review of their own teaching abilities.
• Was there a failure to realize that they alone When things go wrong, good teachers blame
are responsible for their behavior? themselves first; only later do they consider the
• Should another team member have been student/learner might be the source of the prob-
involved? lem. Good teachers constantly learn, evaluate
• Were the educational materials used for teach- themselves, and refine their skills. For them
ing previewed? learning is a lifelong commitment and self-
• Were the correct interventions chosen for the evaluation a lifelong process.
stated objectives?
• Were the objectives realistic?
• Was there disregard or overlook of a skill 16.6.1 Using the Self-Evaluation
deficiency? Checklists
As a teacher, one of the most important skills one Teaching is a complex, many-faceted activity
can possess is the ability to critically evaluate one- with few basic guidelines and a large number
self. It is not a skill that is easily acquired, and it of ways in which it can be successfully carried
requires emotional maturity. But it is one character- out. It is a highly intellectual and personal
istic that distinguishes good educators from the rest. skill. Like all skills, it needs to be periodically
Clark and others [96] devised a ten-point scale assessed and refined. Self-assessment is vital
for assessing teaching and communication behav- and requires a critical look at oneself and the
iors of healthcare providers. The scale was ability to judge one’s work against the follow-
designed to evaluate self-efficacy (the belief that ing points:
one can do something) and outcome expectation.
The first four items on the scale refer to the use of • Clarity of presentation
nonverbal and verbal encouragement when deal- • Variability of presentation
ing with individuals with asthma. The next two • Enthusiasm, involvement, and interest
items deal with discovering the individual’s con- • Goal orientation
cerns and providing reassurance. The seventh • Whether sufficient opportunity was provided
item describes customization of the individual’s for the individual to be involved in the learn-
medication regimen to suit the family’s routine. ing process
The last three items on the scale deal with help- • Involvement of the individual with asthma in
ing the individual make decisions regarding setting and achieving goals
short- and long-term goals. They further extended • Extent to which one displays, inadvertently or
the scale by adding a section on: otherwise, negative emotions
• Use of structuring comments
• Self-regulating behavior with the emphasis on • Type of questions asked
communication skills • Amount of reassurance provided
• Awareness of reactions • Evaluation of results
In addition to a brief, mental review of each easily connect them to obtain a graphical rep-
teaching session, a periodic review of progress resentation of your progress.
from a long-term perspective should be made. To 2. The columns are titled:
make it easy to evaluate and re-evaluate teaching • U/S—Unsatisfactory
ability, a number of self-evaluation checklists are • S—Satisfactory
included in the following pages. They allow teach- • Ex—Excellent
ing to be re-examined in terms of effective behav-
iors, attitudes, and feelings. Used honestly, they Mark your answer by placing your dot or
can help one become an excellent asthma educator. check mark in the column that best suits your
The checklists are not a comprehensive definition feelings about the statement.
of good teaching; instead, they are meant for per-
sonal (and confidential) self-evaluation. Organizational Ability
Another evaluation option is a peer review.
Record how you feel about yourself—not
Self-assessment through peer review has been
how others see you U/S S Ex
tried where a session is videotaped and presented As an asthma educator, the extent to
to the entire group. The presenter states the objec- which I:
tives and defines both needs and wants. This is Establish and implement long-range plans
followed by a discussion by colleagues who pro- is
vide both comments and criticisms. The result is Establish and implement short-range plans
is
self-assessment with discussion on relevant clini- Plan for each individual is
cal issues. Plan for activities and materials to meet
For those who prefer not to do a self-assessment individual needs is
by themselves (and not in front of colleagues), the Plan for the efficient use of time is
checklists provided will be beneficial. They Plan, in cooperation with others, the
material to be covered, is
should be completed every 3 to 6 months. As
Provide for review is
skills and self-confidence improve, the interval Provide for reinforcement (of topics
can be increased until they are completed just covered) is
once a year. Even teachers with many years of Use community resources as an aid to
experience will find them helpful. Grading is done teaching is
by placing a mark (• or ✓) in the appropriate col- Use the individual’s ideas and input in
determining action plans is
umn. The columns are titled U/S for unsatisfac-
tory, S for Satisfactory, and Ex for Excellent.
It is essential to be critical and be honest if Management Ability
these checklists are to be helpful. These tables are
for information and assessment alone. They are a
record of one’s own feelings and deal with per- As an asthma educator, the extent to
sonal evaluations and not evaluation by others. which I:
No one else will see the scores. The checklists are Maintain consistent expectations of
merely an aid to self-evaluation, particularly for behavior of the person with asthma is
the new asthma educator. Encourage self-monitoring is
Encourage self-management is
Cope with disruptions in a positive
manner is
16.7 Self-Evaluation Checklists Resolve an individual’s problems with a
team approach is
Instructions Control digressions in each teaching
session is
1. Grade yourself by placing a dot (•) or a check
Seek help from team members for
mark () in the appropriate column of the potentially serious problems is
tables that follow. If you use dots, you can
Record how you feel about yourself—not Record how you feel about yourself—not
how others see you U/S S Ex how others see you U/S S Ex
Am attentive to the physical conditions in Understand why they are unable to adhere is
which I receive those with asthma Foster a thoughtful, questioning attitude is
Control my reactions to their choice of Provide an appropriate mix between my
self-defeating behaviors is involvement and their involvement in each
Complete required forms accurately and session is
on time is Document what each individual has been
Maintain up-to-date records for each taught is
individual is Document problems with adherence is
Ensure they receive as much time as they Document what worked or did not work for
require to learn about their asthma is each person and why is
Start sessions on time is
Maintain contact with each individual is
Spend the full allotted time for each Cultural Competency
appointment with them is
Teaching Techniques As an asthma educator, the extent to
which I:
Conduct assessments in a culturally
sensitive manner is
As an asthma educator, the extent to
Consider the individual’s culture while
which I:
obtaining the health history and current
Base my methodology on sound learning problems is
theory is
Keep in mind their religion and its impact
Modify my methods to provide a variety of on adherence is
learning experiences is
Conduct culturally based physical
Vary materials to meet individual needs is assessments is
Create/maintain appropriate intellectual Ask them to let me know if I do
and emotional climates for learning is something culturally inappropriate is
Present information so that it is clearly Am forthright with them and admit I do
understood is not know their culture is
Arrange my questions to lead individuals
with asthma to solve their problems is
Use questions to elicit their response at
every level of learning is Evaluation
Tolerate silence after posing a question is
Accept their responses is Record how you feel about yourself—not
Clarify their responses is how others see you U/S S Ex
Capitalize on their pertinent questions is The extent to which my evaluation
Adjust my vocabulary to their level is program is:
Provide a relaxing, nonthreatening, and In keeping with the stated objectives of the
nonjudgmental atmosphere is asthma program is
Lead them to self-awareness of symptoms Consistent with that of other team members
is is
Lead them to self-management of their Consistent with community expectations is
asthma is The extent to which I use evaluation
Teach coping and relaxation skills is results to
Work with them to identify their needs is Analyze effectiveness of teaching is
Work with them to identify their goals is Plan instruction and reviews is
Work to alleviate their concerns is Diagnose strengths and weaknesses of
individual’s is
Work with them to develop self-
management behaviors is Implement strategies to meet their needs as
diagnosed is
Work with them to master necessary
management skills is
16.7.1 Checklist 2 Record how you feel about yourself—not

Educator-Individual Relationships In encouraging self-awareness and
self-discipline is
This section looks at the special relationship that In aiding mastery of skills required is
develops between the asthma educator and the Responsive to individual differences is
individual with asthma. In particular, it attempts In developing a relationship of trust and
to pinpoint attitudes, feelings, and actions which respect is
will lead to an effective relationship. In treating all individuals equally
regardless of race, color, gender, religion,
and socioeconomic status is
Relationships Supportive of their choices is
Tolerant of negative behavior is
A good listener is
Empathetic is
In my relations with those who come to
Interested and supportive of them is
me for education, the extent to which I am
In maintaining a sharing attitude is
Courteous is
In encouraging self-reliance is
Tactful is
In encouraging learning through different
Flexible is
media is
Empathetic is
In encouraging them to seek other
Sympathetic is
resources is
Frank and honest is
Sincere is
Open-minded is
A reasonable person is Team Relations
A good role model for them is
Relaxed and at ease is Record how you feel about yourself—not
Enthusiastic is how others see you U/S S Ex
Consistent is As a team member, the extent to which
Concerned about their welfare is I:
Encouraging is Am enthusiastic and friendly is
Warm to them is Promote harmony in the workplace is
Compassionate is Readily accept my fair share of
responsibility is
Open in communicating with them is
Treat each team member with respect and
dignity is
Make an effort to welcome and offer
assistance to new team members is
Alert and responsive to their needs is
Accept fair and constructive criticism is
Culturally sensitive is
Listen openly to suggestions is
Aware of their feelings, needs and beliefs
Accept the will of the majority is
is
Understand the relationship of my area of
In providing positive reinforcement is
expertise to the others within the context
In ensuring that they feel secure and of the total program is
satisfied is
Share ideas and materials is
In providing suitable physical
Maintain a good working relationship
arrangements for them is
with all team members is
Aware of factors that influence their
Refrain from criticizing the team or
behavior is
individual team members to individuals or
Considerate of familial influence is their families in public is
Considerate of cultural influence is Am not afraid to stand up for what is right
Considerate of religious influence is even if it might affect my popularity is
In providing education for their families is Actively participate by speaking up at
In encouraging them to achieve a little at a team meetings is
time is
Record how you feel about yourself—not Personal Attributes

Feel my colleagues consider me as an Record how you feel about yourself—not
enthusiastic educator and a likeable how others see you U/S S Ex
person to have around is As a person, the extent to which I:
Confer with my colleagues is Show interest in each individual is
Am culturally sensitive to all my Demonstrate warmth, friendliness, a sense
colleagues of humor, and understanding
Am aware of my personal biases and
prejudices is
Am exploring my own cultural and ethnic
Professional Attributes: Knowledge background is
Demonstrate enthusiasm for my job is
Possess a positive self-concept is
Demonstrate poise, self-control and
As an asthma educator, the extent to self-confidence is
which I am:
Demonstrate tact, courtesy, and a
Academically competent is willingness to listen to and understand the
Knowledgeable of learning theories is viewpoints of others is
Knowledgeable of child and adolescent Am committed to self-evaluation and
psychology is self-critique is
Knowledgeable of current asthma research Possess compassion, openness, and
findings is flexibility is
Knowledgeable about the cultural and Possess a well-modulated voice, clear, and
religious practices of the population in my distinct speech habits is
area Demonstrate good grooming and habits of
dress is
Professional Growth Model good work habits which reflect
punctuality, dependability, efficiency, and
Record how you feel about yourself—not accuracy is
how others see you U/S S Ex Demonstrate good health habits and
As a teacher, the extent to which I: physical fitness is
Participate in conferences and workshops Recognize with humility that I am not as
to improve instruction is culturally aware as I should be is
Read professional materials is Am curious about other cultures
Work with colleagues and team members
to improve instructional techniques is
Participate in asthma-related organizations
Conduct periodic self-evaluation of 16.8 Application
instruction is
Conduct periodic self-evaluation of 1. Take the files of ten individuals who have
teaching techniques is asthma and tabulate the following
Conduct periodic evaluation of new
information:
asthma-related materials is
Acquire appropriate skills and information • Age, gender, first date of reported asthma
to improve instruction is symptoms, date of actual diagnosis, and
Enhance my academic development time elapsed between the two dates (i.e.,
through continued formal education before the actual diagnosis of asthma was
activities is
made)
Am motivated to be culturally competent
Work to obtain a sound foundation of the
• Medications and the period of time they
various worldviews of different cultures were used
Develop partnerships with communities • Teaching efforts made toward environmen-
on behalf of individuals tal control
Willing to learn new methods and new • Behavioral changes noted (cessation of
approaches
smoking, elimination of pets, etc.)
Appendix 16.2 605
• Current management Conquering Asthma

2. A friend’s home may be the best place to prac- M. Newhouse and P. Barnes. Decker
tice an assessment. (Of course this friend’s Periodicals Inc.
permission and assistance will be needed.)
Make a list of items you should look for
(review the guidelines in this chapter) and the A Parent’s Guide to Asthma
type of questions you should ask pertaining to Nancy Sander. Doubleday, New York.
lifestyle. Then, pretend that a member of the
friend’s household has asthma and document
what you have observed. Taking finances into Essential Guide to Asthma
consideration, outline a plan that describes American Medical Association. Pocket Books,
what should be done to improve environmen- Simon & Schuster. New York
tal control in the home.
3. Make a list of resource materials and of orga-
nizations that are available in your area (city, Asthma: Questions You Have. Answers You Need
town, or rural). Paula Brisco. People’s Medical Society
4. Select any ten items that are available for

asthma education. Evaluate them according to
the criteria suggested in this chapter. The Canadian Allergy and Asthma Handbook
B. Zimmerman, M. Gold, S. Lavi and
S. Feanny. Random House
Appendix 16.1
Asthma: An Emerging Epidemic
Reading Material for Patients P. J. Hannaway. Lighthouse Press
The following books are excellent reference texts

for use by parents and persons with asthma. They Asthma Allergies Children: A Parent’s Guide
are well written and suitable for a wide range of P. Ehrlich, L. Chiaramonte and H. Ehrlich.
reading and comprehension skills. Note: this list Third Avenue Books
is not comprehensive and should be used merely
as a starting point.
Your Child’s Asthma: A Guide for Parents
One Minute Asthma John F. Hunt
Dr. T. Plaut
An excellent, brief introduction to asthma—
available in English and Spanish
PDF available free at www.AsthmaEd.com/ Appendix 16.2
resources
Internet Addresses
Children with Asthma: A Manual for Parents While there are thousands of sites on the Internet
Dr. T. Plaut, Pedipress, Amherst, MA with asthma information, we suggest that you
recommend only a few to patients. Listed below
are some of the sites that are known to be trust-
Dr. Plaut’s Asthma Guide for People of All Ages worthy. They are also helpful to the asthma
Dr. T.F. Plaut and T.B. Jones. Pedipress, educator.
Amherst, MA
Important note: Internet addresses and web Center for Disease www.cdc.gov
pages can and do change, often quite frequently. Control and
Prevention
To locate a new address, type the organization’s
Food and Drug www.fda.gov
name into any Internet search engine. Administration
Global Initiative for www.ginasthma.com
Asthma
General Interest National Institutes www.nih.gov
of Health
Allergy and Asthma Network www.aanma.org National Heart www.nhlbi.nih.gov
American Academy of www.aaai.org Lung Blood
Allergy, Asthma, and Institute
Immunology National Library of https://pubmed.ncbi.nlm.nih.gov/
American College of Allergy, www.acaai.org Medicine
Asthma and Immunology
American College of Chest www.chestnet.org
Physicians
American Academy of www.aafp.org
Family Physicians Appendix 16.3
American Association of www.aai.org
Immunologists uggested Reading for Asthma
S
American Association for www.aarc.org Educators
Respiratory Care
American Lung Association www.lungusa.org
American Medical www.ama-assn.org Note: this list is not comprehensive.
Association
American Thoracic Society www.thoracic.org National Asthma Education and Prevention
Asthma and Allergy www.aafa.org Program Expert Panel Report 3. Guidelines
Foundation of America
for the diagnosis and management of asthma.
Asthma Canada www.asthma.ca
Canadian Lung www.lung.ca/asthma
NIH pub #12–5075. Revised September 2012.
Association—Asthma 2020 Focused updates to the asthma management
Canadian Network for www.cnrchome.net guidelines: a report from the National Asthma
Respiratory Care Education and Prevention Program Coor
Food Allergy Research & www.foodallergy.org dinating Committee Expert Panel Working
Education
Group. NIH publication No. 20-HL-8140.
International Food www.foodinsight.org
Information Council December 2020.
Foundation Global Initiative for Asthma. Global strategy for
Mayo Foundation for www.mayoclinic.com asthma management and prevention. 2020.
Medical Education and Available from www.ginasthma.org
Research
National Jewish Medical and www.nationaljewish.org
AARC Clinical practice guidelines: providing
Research Center (Lung Line) patient and caregiver education. Respir Care.
2010; 55(6):765–760. Available at http://rc.
rcjournal.com/content/55/6/765.short
Manual of Asthma Management. Ed: P O’Bynne
or Asthma Educators (Not
F and NC Thomson. WB Sanders Company
for Patients) Ltd., London. 2000
Govias GD. Effective Teaching Techniques.
American College www.acponline.org 2017. The Asthma Education Clinic, www.
of Physicians
Asthma Education www.asthmaed.com
AsthmaEd.com
Clinic
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Part IV
Case Studies
Case Studies
17
Contents
17.2 Instructions for Case Studies 1 to 14 614
17.3 Additional Case Studies 614
17.4 Case Study 1 614
17.5 C
ase Study 2 614
17.5.1 Response to Case Study 1 615
17.7 C
ase Study 4 615
17.8 C
ase Study 5 616
17.9 C
ase Study 6 617
17.13 Case Study 10 622
17.14 Case Study 11 623
17.15 Case Study 12 623
17.16 Case Study 13 624
17.17 Case Study 14 625
614 17 Case Studies
17.1 Introduction 17.3 Additional Case Studies
Currently, there are only a few independent “Case studies for asthma educators,” available at
American asthma educators in the USA. Most www.AsthmaEd.com, offers 124 case studies of
work in clinics as part of a larger team, and, in increasing complexity to further improve your
most cases, people with asthma are referred to skills.
them by one or more of the healthcare profes-
sionals working there. Over the next few years, it
is likely that the number of independent educa- 17.4 Case Study 1
tors, with their own clinics, will increase.
However, the pattern of referral will change very Scenario
little. A 16-year-old girl has been sent to see you,
The case studies in this chapter have been the asthma educator. She was wheezing at a rou-
devised to work equally well for all asthma edu- tine health assessment before summer camp and
cators—those who work for themselves and was prescribed albuterol, told that she had
those in a clinic. Each case study is based on the asthma, and should receive more education on
assumption that a person with one or more respi- this topic. She has had asthma episodes once or
ratory problems has been referred to the asthma twice in the past but currently has no symptoms.
educator, who must now make a decision or take She is not active in sports. She tells you that she
some action. wakes most nights with coughing.
Questions
17.2 I nstructions for Case Studies 1 . What should be the focus of your education?
1 to 14 2. Should you suggest that she seek prescription
treatment, such as cough syrup at bedtime, for
The person with asthma makes: the nighttime coughing?
3. Should you advise her to avoid sports because
• A single visit in case studies 1 through 4 of her asthma?
• Three visits in case studies 5 though 14
Read the information provided, answer any 17.5 Case Study 2

questions that are asked, and indicate what steps
you would take to help them. Scenario
Use a separate sheet of paper for each visit. An elderly woman, aged 70, comes to see you.
For multi-visit situations, treat each visit in She has recent onset of wheezing. She says that
turn, writing your answer before continuing she was “chesty” as a small child. She has been
to the next visit. With each successive visit, prescribed a bronchodilator which helps to some
you will learn more about the person. Hence, extent, but she wishes to know more about the
you will have to adapt or refine the instruction asthma and whether she can control it without
and education you provided in the previous medication. She is otherwise healthy but was
visit. recently given eye drops by her physician for
After you have completed your answers to glaucoma.
all the visits in a case study, then and only then Questions
should you turn the page, since suggested
answers or responses are printed on the next 1. What possible features in the history are

page. important?
Suggested responses are provided for case 2. What advice will you give her on managing
studies 1 through 9. the asthma without a bronchodilator?
Turn the page only after you have completed beta-blocker. If so, then she should contact the
your answers. prescriber and request an alternative treatment
for her glaucoma.
2. Drug interaction is an ongoing problem. To
17.5.1 Response to Case Study 1 avoid this, patients should ideally obtain all
prescriptions from a single healthcare pro-
1. Using history and spirometry, it is important vider. When this is not possible, patients
to determine whether she has chronic symp- should use only one pharmacy for their medi-
toms. Nighttime coughing and awakening are cations. Often, the pharmacist will detect
indicative of uncontrolled asthma. Lack of “conflicting” medications and warn the
participation in sports is yet another indica- patient. If medications have to be obtained
tion. It is possible that she does not exercise from different pharmacies, patients should
because it brings on asthma symptoms, and give a list of all their medications to each
this needs to be explored. She probably needs pharmacist.
daily inhaled corticosteroids, and this needs to 3. Meanwhile, she needs effective treatment to
be discussed in an educational and informa- control the asthma with the bronchodilator.
tive way with the family. The healthcare pro- Make sure that she knows how to use the
vider should be consulted about a prescription bronchodilator device properly.
for inhaled corticosteroids. 4. If she wishes to manage her asthma without a
2. Cough syrup will not help the asthma symp- bronchodilator, an environmental review of
toms. Once the asthma is under control, night- her home is needed. Identifying possible trig-
time symptoms will stop. gers and explaining how she can minimize her
3. Exercise in the form of sports will benefit her exposure to those triggers will be beneficial.
general health. It is important that she exer-
cise. To this end it would be beneficial to
ensure that the asthma is well controlled. If 17.6 Case Study 3
symptoms persist or are brought on by exer-
cise, then teaching her to: Scenario
• Premedicate with a bronchodilator A male, aged 50, consults you. He is a manual
• Perform a slow warm-up (before exercise) worker for the city, has become progressively
and a slow cooldown (after) will prevent short of breath, and is finding it difficult to com-
further symptoms. plete his work. His healthcare provider has told
him he has asthma, and he wishes advice from
You should also ensure that she knows how to you on how to control it.
use her bronchodilator device properly. If possi- Questions
ble, suggest that the same type of device be pre-
scribed for the inhaled corticosteroids. 1. What further information do you need from
With appropriate treatment, she can exercise him?
fully. 2. What action will you take as an educator?
3. What information will you provide his health-
care provider?
17.5.2 Response to Case Study 2
1. Note that this elderly person has recently been 17.7 Case Study 4
given eye drops for her glaucoma. The eye
drops may contain a beta-blocker that triggers Scenario
the asthma. Ask her to contact her pharmacist You are consulted by a 35-year-old male who
in order to find out if her eye drops contain a is active athletically. He can no longer play
616 17 Case Studies
squash. When he talked to his healthcare pro- 2. Does he have any other symptoms? Does he
vider, he was told he has asthma and was pre- wake at night, cough, or have shortness of
scribed inhaled corticosteroids. He did not like breath? Does he have nighttime symptoms or
this advice and wants to deal with his asthma wheeze on days when he is not exercising?
without medication. How does he react to colds? Do they take
Questions more than a week to clear up? Does he have
hay fever? Does he have seasonal symptoms?
1. Is it possible to manage his asthma without And so on.
medication? 3. If his symptoms are exercise-related, then pro-
2. What further information do you need? vide a simple explanation of how to handle
3. What advice would you give him? exercise. Explain the “premedication, slow
warm-up, and slow cooldown routine” that he
Turn the page only after you have completed should follow each time he exercises. If exer-
your answers. cise appears to be his only problem, show him
the various devices for bronchodilators.
17.7.1 Response to Case Study 3 If the symptoms are only partly related to
exercise, he may need inhaled corticosteroids to
1. Prepare a detailed smoking history. Establish bring his asthma under control. Provide educa-
whether he has had a full medical evaluation, tion on inhaled corticosteroids and their purpose,
including chest x-ray and spirometry, to and teach him to use the prescribed device. If it is
exclude other lung or heart diseases which an MDI, stress the use of a spacer device as well
may cause dyspnea. as the importance of rinsing his mouth after an
2. Explore both the home and work environment inhalation of the corticosteroid.
in considerable detail. Ask about all previous
jobs, not just the current one. If he can identify
his triggers, explain how he can minimize his 17.8 Case Study 5
exposure to them. If there are major environ-
mental issues connected with his work that Instructions
cannot be changed, discuss with him the pos- Do not read the entire page.
sibility of changing his job. Could he stay Read only the information provided for the
with his employer but work in a different area first visit; then use a separate sheet of paper to
in order to avoid exposure to his triggers? write your answers.
3. Show him the various devices used to deliver Next, read the information provided for the
asthma medications, and suggest that he talk second visit and again; write down your answer.
to his healthcare provider to decide which Do the same for the third visit. Turn the page
device would be best for him. If he has already only after you have completed your answers to all
been prescribed a device, ensure that he knows three visits, and review the suggested responses.
how to use it correctly.
First Visit
Scenario
17.7.2 Response to Case Study 4 A father brings his 9-year-old son to see you.
This boy has been enrolled in a hockey team but
1. It is possible to manage asthma without medi- finds he is unable to complete his “shifts” when
cation if: he is sent on the ice. The father believes that the
• The asthma is otherwise under good control boy needs more exercises to strengthen him.
• The sports environments (surroundings) He was previously healthy and visits his fam-
are warm ily physician just once or twice a year. The boy
• There is a good warm-up period has now been diagnosed with asthma.
Question relief but does not do anything to help the under-

What role would you have following the boy’s lying inflammation.
visit to his family physician? Check the boy’s technique to make sure he is
using the prescribed device correctly.
Second Visit You must also suggest that the parents dis-
Scenario cuss regular prophylactic treatment with the
The boy has seen the physician and has been boy’s healthcare provider. They may wish to ask
prescribed a bronchodilator. The father feels that for a pulmonary function test, which would con-
this has helped but mentions that the boy has firm the diagnosis of asthma and also give them
occasional problems at night following an epi- some idea of the degree of obstruction in the
sode of asthma. airways.
Question
How would you respond? Third Visit
The parents and their son must understand what
Third Visit asthma does to the lungs and the role of inhaled
Scenario corticosteroids in its treatment. Explain that
The boy has had a pulmonary function test inhaled corticosteroids require a minimum of a
done. Because his FEV1 was reduced, he was pre- week in order to work, and hence it is important
scribed a low dose of inhaled corticosteroids. The to keep taking them until all the inflammation is
father feels that he is much stronger and suggests gone. The lungs need time to heal, and it is also
that after 1 week or so of inhaled corticosteroids, important to prevent another asthma attack. Once
this treatment should be stopped so that his son the asthma is well controlled, it may be possible
can become stronger. to reduce the inhaled corticosteroids, but not till
Question then.
How do you respond? Check that the boy is using the inhaled corti-
Turn the page only after you have completed costeroid device correctly. Ensure that he
your answers. knows how to care for the device and to tell
when it is empty. Remind him that he must
rinse his mouth after inhalation. If the medica-
17.8.1 Response to Case Study 5 tion is in an MDI, then a spacer will be neces-
sary. Explain its use.
First Visit
You must review the mechanisms involved in
exercise-induced asthma and then talk about 17.9 Case Study 6
medication-free methods of reducing its impact.
Premedication followed by a slow warm-up Instructions
(before the game) and a slow cooldown (after the Do not read the entire page.
game) will help the boy. Ensure that he knows the Read only the information provided for the
purpose of the medication prescribed and that he first visit; then, on a separate sheet of paper, write
knows how to use the prescribed device your answers.
properly. Next, read the information provided for the
second visit and again; write down your
Second Visit answer.
At this stage you should talk to the family about Do the same for the third visit. Turn the page
chronic inflammation and exercise-induced only after you have completed your answers to
asthma. Explain that the bronchodilator is a all three visits, and review the suggested
reliever medication that provides symptomatic responses.
618 17 Case Studies
First Visit Turn the page only after you have completed
Scenario your answers.
A girl, aged 3 years, is brought to you, the
asthma educator, by her grandmother. Both par-
ents work, and the child is usually left at a day 17.9.1 Response to Case Study 6
care facility. On this occasion, the grandmother
has brought her from day care to see you. First Visit
The grandmother tells you that the child’s Explore carefully whether or not there are any
mother (her daughter) had asthma as a child but symptoms between these episodes or whether
this went into remission. The granddaughter they are all discrete. Observe the child externally
started wheezing with a cold at the age of for degree of dyspnea, size, and developmental
13 months. She now wheezes every month with a status.
cold and has been prescribed a bronchodilator If necessary, show the family various means
(albuterol syrup). The mother thinks this helps, of drug delivery, including metered dose
along with an antibiotic which is always given. inhaler with a spacer and a nebulizer. Provide
She notes that the child is “wired” each time she them with information on the inflammatory
gets an infection and thinks it is because her other nature of asthma and common triggers. Obtain
grandmother gives her sugary treats at those or do an environmental history of the home.
times. Advise them to see their healthcare provider
Questions for consideration of prophylactic treatment or
for some anti-asthma treatment in addition to
1. On the first visit, what further questions
the bronchodilator. It might be possible to
should you ask? manage this girl with ICS during an attack
2. What observations should be made of the
alone, as she does not seem to have interval
child? symptoms. You can point out that albuterol’s
3. What education would you provide her? side effects are more likely with syrup than
with a metered dose inhaler. This applies par-
ticularly to hyperactivity. Sugar does not cause
Second Visit hyperactivity.
Scenario Remember that in the first few years of life,
The child’s mother took her to the healthcare children get between 6 and 12 colds per year.
provider, and albuterol nebulizer has been pre-
scribed. This has been used during one episode of Second Visit
cold but seems to make little difference. Check that the nebulizer is functioning properly
Question and that the parents are using it appropriately and
What action should you take now? correctly. Again, briefly explain the various
classes of medication used with asthma, and
Third Visit encourage the family to discuss these further with
Scenario their healthcare provider.
By this time, the family has been referred to a Albuterol usually helps a child who is
specialist, and inhaled corticosteroids are being wheezing but may not always do so. Even
used. The mother and grandmother are both con- with a diagnosis of asthma, inhaled cortico-
cerned as the dose of inhaled corticosteroids is steroids may sometimes be needed. The edu-
higher than described in the package insert, cator should offer information to the family
which also states that the drug is intended for on asthma in general and also discuss the role
children over 4 years only. of inhaled corticosteroids and when they
Question might be given every day, as opposed to only
How do you respond to this new concern? when ill.
Third Visit Next, read the information provided for the

second visit and again; write down your
1. Reassure the family that this treatment is com- answer.
monplace. Review the use of medication in Do the same for the third visit. Turn the page
children of this age. Remember that because it only after you have completed your answers to
is difficult to ensure effective drug delivery to all three visits, and review the suggested
the lungs, a larger dose is often used than responses.
would seem appropriate based on weight. The
child’s smaller lung size will correct for this. First Visit
Review also the licensing process. Medications Scenario
are licensed by different classes, and the com- A pregnant woman of 27 visits you. This is
pany submitting the request for the drug has to her first pregnancy. She has had asthma for
provide evidence of safe use for different ages 6 years that is well controlled with inhaled cor-
and in both sexes. It sometimes happens that ticosteroids. She is very concerned about the
there is less information on younger children fetus and comes to you for advice on manage-
than on older children. ment of asthma without drugs throughout the
A drug is licensed for specific indications pregnancy.
and specific populations. Thereafter it may be Questions
prescribed by a licensed practitioner for any
indication. The drug may not be licensed for a 1. Is it reasonable to expect to be able to manage
particular indication in a particular country, asthma without medication?
but there may be good clinical experience 2. Are there concerns about the safety of the
with the drug or good literature from other medication during the pregnancy?
companies. Inhaled corticosteroids by MDI 3. How would you coordinate matters with other
are in widespread use in infants and young healthcare professionals over this individual?
children and seem to be safe. Parents need to
make an informed choice based on their
assessment on the amount of discomfort the Second Visit
wheezing is causing. Scenario
2. Review the parents’ technique when they use The woman has returned with the reading
the metered dose inhaler and spacer, and material that you gave her. She now has major
check that the technique is appropriate. problems with her eyes and asks about antihista-
3. Explain how drugs are distributed for children mines. She also asks if there is any over-the-
of this age and the licensing process. counter product she can buy without going to a
Sometimes, the manufacturer may choose not healthcare provider.
to apply to have a particular age group added to Question
the licenses to save the expense of doing the What recommendations would you make?
research needed to justify the change. Reassure
the adults that the prescription is appropriate. Third Visit
Scenario
She comes to see you with her new baby who
17.10 Case Study 7 is 6 weeks old. She is breast-feeding and asks for
advice on what foods she should avoid while
Instructions breast-feeding.
Do not read the entire page. Question
Read only the information provided for the What advice do you offer this new mother?
first visit; then, on a separate sheet of paper, write Turn the page only after you have completed
your answers. your answers.
620 17 Case Studies
17.10.1 Response to Case Study 7 17.11 Case Study 8
First Visit Instructions

Do not read the entire page.
1. The fact that this woman is motivated to do Read only the information provided for the
everything possible to minimize any use of first visit; then, on a separate sheet of paper, write
medication is something you should use. Tell your answers.
her the best way to manage her asthma is Next, read the information provided for the
through strict environmental control and trig- second visit and again; write down your
ger avoidance. Thus, there should be a major answer.
environmental review of the home and the Do the same for the third visit. Turn the page
nature of the asthma in the woman. only after you have completed your answers to
2. Inhaled corticosteroids are safe during preg- all three visits, and review the suggested
nancy but, as with other asthma medications, responses.
should only be used when necessary and in
the minimum strength or dose needed to First Visit
maintain control. It is important to reaffirm Scenario
that her asthma must be well controlled, since You have been consulted by a man of 45 who
hypoxemia is of some risk to the fetus. lives in Montana and works in a sawmill, work-
3. She should be encouraged to discuss her fears ing directly with lumber. He has been wheezing
with the professional(s) responsible for preg- constantly for 4 months. He has been advised
nancy care. She needs to be reassured that tak- that he may have an occupational disability but
ing care of herself and controlling her asthma is reluctant to leave his job. He wishes advice
is in the best interests of her baby. As her edu- on face masks and how he can control the
cator, ask for permission to let the other mem- asthma.
bers of the healthcare team know about her Questions
fears. Her level of concern will have a direct
bearing on whether she should be referred to a 1 . What information will you give him?
psychologist for further help. 2. How do you provide support?
Second Visit Second Visit

Talk about her asthma. Is it seasonal? Tell her that Scenario
antihistamines purchased over the counter are not He has continuing problems and has accepted
recommended, particularly since she is pregnant. that he will have to leave his job. He wants to
She should check with her doctor as to what discuss alternate occupations with you.
would be safe both for her and for the baby.
Does she have allergies? Rhinitis? Third Visit
Scenario
Third Visit He has left his job in the sawmill and now
Ask her about her triggers and allergies. Remind her works as a parking lot manager. However, he is
that it is important that she have a well-balanced still wheezing. He is angry that his wheeze was
diet. There are no specific foods that she should not resolved after he left the sawmill.
avoid, unless she is allergic to them. However, while Question
breast-feeding, she should avoid foods that have What will your answer be?
allergenic potential such as peanuts, tree nuts, shell- Turn the page only after you have completed
fish, etc., to avoid possibly sensitizing the infant. your answers.
17.11.1 Response to Case Study 8 also become increasingly sensitive to things that
did not cause problems before he had the attack.
First Visit Hence, he must make every effort to avoid any-
If this gentleman does have occupational asthma, thing that would irritate his lungs. An explanation
explain why he must look for a different job. of the purpose of the medications as well as a rou-
A face mask will generally not be sufficient. tine checking of technique will also help.
At best, it offers temporary protection and
reduces exposure by inhalation to some extent.
However, if wood is a trigger, then the fine wood 17.12 Case Study 9
particles that attach themselves to his clothing
will cause problems when he gets home and Instructions
removes his mask. The mask is not a solution. Do not read the entire page.
Now that he is sensitized, he must avoid the Read only the information provided for the
things that cause his wheezing. It will require a first visit; then, on a separate sheet of paper, write
great deal of time to explain this. your answers.
The worker will be able to control his asthma Next, read the information provided for the
by avoiding his triggers and using medication to second visit and again; write down your answer.
control the existing inflammation. Find out what Do the same for the third visit. Turn the page
medications have been prescribed, and ensure only after you have completed your answers to
that he uses any prescribed devices correctly and all three visits, and review the suggested
that he takes the necessary steps to avoid side responses.
effects. Tell him what he must do to achieve con-
trol of his asthma. First Visit
Suggest that he obtain a referral from his phy- Scenario
sician and/or healthcare provider to the US A mother comes to see you with her 7-month-
Department of Rehabilitation Services. old child. She tells you that the child started
wheezing shortly after her birth and was pre-
Second Visit scribed albuterol by nebulizer, to which was
What symptoms does he have? Is he taking his added inhaled corticosteroids by nebulizer.
medications to control his asthma? Why is he Neither of these treatments seems to have helped,
having continuing problems? What concerns him and the wheeze has not improved.
the most regarding his asthma? Questions
His choice of occupation will depend on his
level of skills. Can he work in an office? What 1. What other questions should you ask the

does he think he can do? What does he feel are mother?
his options? 2. What observations should be made of the

child?
Third Visit 3. What education about asthma would you

You will need to question him carefully to find provide?
out why he continues to wheeze:
• Is he taking his medications properly? Second Visit

• Has he found other triggers for his asthma? Scenario
• Is he being exposed to diesel and gasoline The mother returns 2 weeks later and tells
fumes in his new job at the parking lot? you the healthcare provider has increased the
albuterol and is considering adding prednisone.
It may help to explain that not only do the lungs She wonders if there is other advice you can
require time to heal after an asthma attack but they offer.
622 17 Case Studies
At this stage, she has not seen a specialist, and cussed with the healthcare provider. There may
there have been no other tests ordered or an x-ray. be apprehension about this. Take time to help the
The child seems happy. mother with some role-playing, so that she can
Review the answers and advice you provided rehearse that discussion with the healthcare
after the first visit, and consider what further provider.
exploration you should do and what action you Repeat this advice after the second and third
should take. visit. Establish whether or not there are pets and/
or smokers in the home. Provide reading material
Third Visit on asthma, particularly if it points out the need
Scenario for another opinion or investigations, and suggest
The mother comes to see you 1 month later. that she contact organizations such as an allergy
The child has never been ill but has not really and asthma association or the local chapter of the
improved. The wheeze continues despite an lung association.
increase in the inhaled corticosteroids and the As the educator, you need both to maintain a
albuterol. good relationship with local healthcare providers
Questions and also to provide good care. Thus, by providing
various ways for the mother to reach her own
1 . What can you, as an educator, do at this stage? conclusion that a second opinion or further inves-
2. Are there difficult issues to be faced? If you tigation is needed and allowing the mother to
can identify these, how would you counsel the rehearse and role-play the request for a second
mother to handle them? opinion, ethical needs can be met.
Turn the page only after you have completed

your answers. 17.13 Case Study 10
Instructions
17.12.1 Response to Case Study 9 Do not read the entire page.
Read only the information provided for the
On the first visit, ask the mother if the child is first visit; then, on a separate sheet of paper, write
growing normally and if there is any other evi- your answers.
dence of disease such as diarrhea or other allergic Next, read the information provided for the
diseases such as eczema. Also ask the mother if second visit and again; write down your answer.
there is any family history of lung disease. Do the same for the third visit. Turn the page
The child should be examined for general only after you have completed your answers to all
affect, whether obviously breathless or whether three visits, and review the suggested responses.
coughing or wheezing during the time of the
interview. First Visit
At this stage it would not be appropriate to Scenario
provide education about asthma. This child may A woman of 40 consults you. Over the last
not have asthma. Wheeze starting shortly after 4 months, she has woken up every night at about
birth is unusual in asthma, and the child’s poor 3 a.m. She finally falls sleep after 1 hour of pro-
response to albuterol and inhaled corticosteroids longed coughing and breathlessness. Her health-
is also unusual. However, even in asthma, there care provider has prescribed a cough syrup at
may not be a good response at this age. night. She now feels slightly drowsy in the morn-
This can be a difficult situation. You may wish ing but still coughs.
to handle it by indicating that healthcare provid- She was at a presentation on respiratory dis-
ers often consider other tests or referral when ease and realized that she may have asthma. She
infants are wheezing, and ask if this has been dis- has come to you for advice.
17.15 Case Study 12 623
Questions all three visits, and review the suggested

responses.
1. What further information do you need from
her? First Visit
2. What should your initial response be? Scenario
3. What information would you give to her
A healthcare provider asks you to educate a
healthcare provider? young woman, age 21, who arrived in the emer-
gency department with wheezing. She has never
previously wheezed, but the healthcare provider
Second Visit has diagnosed asthma and suggested that she
Scenario visit you for education.
Her healthcare provider has now added alb- Questions
uterol inhaler to the cough syrup prescribed ear-
lier and has suggested that she get instruction on 1 . What further information do you need?
using the albuterol inhaler. 2. What further information will you provide?
Questions 3. How frequently should you see her?
1. What teaching techniques do you have for the

albuterol inhaler? Are there alternatives to this Second Visit
mode of drug delivery? Scenario
2. She wonders about other approaches to
Following the first visit and a prescription of
asthma, and she has been reading about inhaled corticosteroids, the woman improves.
inhaled corticosteroids. Her healthcare pro- You have shown her how to use a metered dose
vider has explained that these medications are inhaler and a spacer. She mentions that she had
dangerous. How would you respond? coughed as a child—her parents told her this. She
also notes that in the previous 6 months she has
found a new boyfriend whose roommate has a
Third Visit cat. She asks if the cat should be removed from
Scenario the apartment when she visits.
She has returned to her healthcare provider
and obtained a prescription for an inhaled steroid Third Visit
and wishes to discuss her concerns about steroids Scenario
with you. She visits you 3 months later to tell you that
Question she is pregnant and explains that she will now
What other information should you give her? stop the inhaled corticosteroids and asks you to
suggest ways to deal with her asthma during the
pregnancy.
17.14 Case Study 11
Instructions 17.15 Case Study 12

Do not read the entire page.
Read only the information provided for the Instructions
first visit; then, on a separate sheet of paper, write Do not read the entire page.
your answers. Read only the information provided for the
Next, read the information provided for the first visit; then, on a separate sheet of paper, write
second visit and again; write down your answer. your answers.
Do the same for the third visit. Turn the page Next, read the information provided for the
only after you have completed your answers to second visit and again; write down your answer.
624 17 Case Studies
Do the same for the third visit. Turn the page Read only the information provided for the
only after you have completed your answers to first visit; then, on a separate sheet of paper, write
all three visits, and review the suggested your answers.
responses. Next, read the information provided for the
second visit and again; write down your answer.
First Visit Do the same for the third visit. Turn the page
Scenario only after you have completed your answers to
A woman brings her 2-year-old child to you. all three visits, and review the suggested
Her healthcare provider has diagnosed this child responses.
with asthma. You learn in conversation that her
husband died 4 months ago at the age of 30 with First Visit
asthma. Scenario
Questions A single woman with asthma, aged 48, lives
alone. She has cats, knows she is allergic to them,
1. What are the issues likely to arise in your con- but refuses to give them up. She sleeps sitting up
versation with the woman? with a cat on her lap.
2. What further information do you need? Her drug therapy includes salmeterol, a long-
3. What advice will you give at this stage? acting theophylline, ipratropium, and albuterol,
high-dose inhaled steroid, and long-acting anti-
histamine. She also takes 60 mg of prednisone
Second Visit daily.
Scenario Her family considers her lazy since her asthma
You establish that there is a dog in the home, makes it difficult for her to hold down a job.
and the mother feels the loss of this dog would be Following a visit to a new healthcare provider
very difficult for her shortly after the loss of her (she changed healthcare providers after the previ-
husband (the child’s father). ous one insisted that the cats leave), you are asked
Questions to see her as an educator.
Questions
1. What action can you suggest in respect to the
dog? 1 . Comment on her present drug therapy.
2. What other help can you provide? 2. Are there any suggestions you can make that
would improve her environment?
Third Visit
Scenario Second Visit
The child has persistent wheezing. The dog is Scenario
kept outside the house, and the inside of the She comes to you 1 month later She reports
house is rigorously cleaned (to remove dog hair). that she has washed the cat four times in that time
The child has been given a prescription for alb- period. She reports improvement in her asthma
uterol by nebulizer, and prednisone to be taken and suggests that your earlier advice was
with a cold. “misguided.”
Comment on the regimen and other approaches Question
to drug delivery in a child of this age. What further action can you take at this time?
Third Visit
17.16 Case Study 13 Scenario
She comes to see you again 2 months later.
Instructions She is now regularly washing the cats and taking
Do not read the entire page. the medication appropriately. She is on 20 mg of
17.17 Case Study 14 625
prednisone per day with occasional use of alb- educator for advice on how to control the allergy
uterol. She is angry that her brother will not allow so that the relationship can continue.
his children (both of whom have mild asthma) to Questions
visit her.
1 . What else do you need to know?
2. What advice will you give him on control of
17.17 Case Study 14 pets?
Instructions
Do not read the entire page. Second Visit
Read only the information provided for the Scenario
first visit; then, on a separate sheet of paper, write He has had a pulmonary function test, and spi-
your answers. rometry shows an FEV1 of 70% predicted. He is
Next, read the information provided for the now receiving inhaled corticosteroids.
second visit and again; write down your answer. Question
Do the same for the third visit. Turn the page How do you respond to this new situation?
only after you have completed your answers to
all three visits, and review the suggested Third Visit
responses. Scenario
The relationship continues, the pets are kept in
First Visit one part of the house, the house is carefully
Scenario cleaned, and with the use of inhaled corticoste-
You are consulted by a male, aged 43, who roids, he has few symptoms. He tells you that the
had asthma as a child. It went into remission. He woman is now pregnant and he wants to know if
divorced 5 years ago and recently struck up a there is any chance that the child will be allergic
relationship with a woman who has pets. He has to pets.
had an allergy assessment and knows that he is Question
allergic to pets. He consults you as an asthma How do you respond?
Glossary
ABPA Allergic bronchopulmonary aspergillo- ADRENERGIC Refers to adrenaline (epineph-

sis. An allergic reaction in the lungs due to the rine) type activity.
fungi aspergillosis. ALBUTEROL See salbutamol.
ACE Angiotensin converting enzyme. See also ALLERGEN Antigen that stimulates IgE
ace inhibitor. production.
ACE INHIBITOR Angiotensin-converting enzyme ALLERGY A hypersensitivity phenomenon
inhibitor that prevents conversion of angio- that follows exposure to a particular antigen
tensin I to angiotensin II (a powerful vaso- (allergen) resulting in harmful immunologic
constrictor). The inhibitor is used to relieve consequences.
hypertension. About 10% of patients taking ALVEOLI Air sacs where exchange between
ACE inhibitors develop cough that disappears carbon dioxide and oxygen take place.
when the drug is stopped. ALVEOLAR DUCTS Air passages in the lung
ACTH Adrenocorticotrophic hormone. A hor- that connect air sacs.
mone excreted by the pituitary gland that ALVEOLAR SACS Air sacs where carbon
stimulates production of corticosteroids by dioxide is exchanged for oxygen.
adrenals. ANAPHYLACTOID A reaction which is clini-
ACETYLCHOLINE A substance in the body cally very similar to anaphylaxis. Not IgE-
that allows messages to travel from parasym- mediated, but caused instead by direct release
pathetic nerves to other tissues such as mus- of mediators.
cle. If overproduced it leads to contraction ANAPHYLAXIS A potentially life-threatening
of smooth muscle, dilatation of blood ves- systemic allergic reaction, often explosive in
sels, and mucus secretion. These actions are onset.
blocked by anticholinergics (ipratropium is ANGIOEDEMA A reaction, sometimes aller-
the only one in use). gic, seen in the deep skin, with swelling which
ACO Asthma COPD overlap. is not well circumscribed, often found in loose
ADRENAL GLAND Situated on the kidney. connective tissues such as the face, eyelids,
One part, the cortex, produces the steroid hor- lips, tongue, and extremities. Sometimes there
mone cortisol from which corticosteroids used are accompanying hives. In typical hereditary
in treatment are derived. Other steroid hormones angioedema, there are no hives.
are androgens (male sex hormones), produced ANTIBODIES Protein molecules produced by
mainly in the testes, and estrogens (female sex B lymphocytes in response to exposure to for-
hormones) produced mainly in the ovaries. A eign antigenic substances including bacteria,
separate part of the gland (the medulla) pro- viruses, allergens, etc.
duces epinephrine and norepinephrine. ANTIGEN A foreign substance that causes an
ADRENALINE See epinephrine. immune response in the body.
ADRENORECEPTORS See receptors. ARRHYTHMIA Irregular beating of the heart.
ALPHA RECEPTOR See receptors.
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature 627
Switzerland AG 2021
I. Mitchell, G. Govias, Asthma Education, https://doi.org/10.1007/978-3-030-77896-5
628 Glossary
APNEA Cause or absence of breathing, called BRONCHUS/BRONCHI Air passages in the

central when there is complete absence of lung through which air passes in and out. The
breathing movements and obstructive when walls have a complex structure with an inner
there are ineffective breathing movements. layer of mucous membranes and cilia, then a
See also obstructive apnea syndrome layer of smooth muscle around this, finally
(OSA). supported by a layer of fibrous tissue with
ARDS Acute respiratory distress syndrome. some cartilage. Intermediate in size between
ASA Acetylsalicylic acid (aspirin). trachea and bronchioles.
ASPERGILLUS A common fungi associated CANDIDIASIS (also known as moniliasis) A
with decomposition. fungal infection commonly found on the skin
ASPIRATION The entry of foreign material, and mucus membranes. May be seen in the
such as food or vomitus, into the lungs. throat (oral thrush) in patients with asthma
ATOPIC Hereditary tendency to develop IgE as a complication of ICS use. Candidiasis is
antibodies which cause an immediate allergic more likely in patients with diabetes mellitus,
reaction. on antibiotics, pregnant, using birth control
AUTONOMIC SYSTEM Part of the nervous pills, or if depressed cell-mediated immunity,
system that regulates by involuntary mecha- e.g., cancer treatment or acquired immune
nisms such things as blood pressure. deficiency syndrome (AIDS).
BASAL CELLS Any one of the cells in the CARINA The part of the trachea that divides
base layer of the epithelium. into two bronchi.
BASEMENT MEMBRANE The deepest layer CAROTID BODY A small structure at the
of tissue that secures the epithelium. branch of the carotid artery with nerve tissue
BASOPHIL A phagocytic white blood cell responsive to O2, CO2, and pH in the blood and
with large blue staining granules which con- part of the system which controls breathing.
tain histamine and heparin. They look and CARTILAGE Connective tissue without blood
function very much like mast cells which are vessels, but which is firm and elastic. It is
found in tissue. found in joints and the walls of thoracic tubes
BETA-ADRENERGIC (BETA-AGONIST) and in many parts of the skeleton. It is uni-
Beta receptor (agonist) stimulant used in treat- formly present in the skeleton in fetal life and
ment of asthma. See receptors. is gradually replaced by bone.
BETA-RECEPTOR See receptors. CATABOLISM The process through which
BID Bis in die; twice a day. cells release energy by breaking down com-
BRADYCARDIA A slow regular heartbeat. plex substances into simple compounds.
BRONCHIOLE Small airway of the respira- CEREBRAL CORTEX A thin layer of gray
tory system. matter on the surface of the brain.
BRONCHITIS Inflammation and swelling of CERVICAL NERVE Nerve leaving the cervi-
the mucous membranes of the bronchi. cal part of the spinal cord.
BRONCHODILATOR A substance that CHEMORECEPTOR A sensory nerve acti-
relaxes airway smooth muscles, resulting in vated by chemicals, such as the one in the
bronchodilation. carotid artery that is sensitive to carbon diox-
BRONCHOPULMONARY Involving the ide, oxygen, and pH in the blood and signals
bronchi of the lungs. the respiratory center in the brain to increase
BRONCHOPULMONARY DYSPLASIA or decrease breathing.
Chronic changes in the lungs of premature CHOLINERGIC Referring to nerve fibers that
infants following treatment with assisted release acetylcholine.
ventilation. This often requires prolonged CHOANAE The passages separating the nasal
supplementary oxygen therapy. These babies cavity from the nasopharynx.
commonly wheeze. CHROMOSOMES Long pieces of DNA
BRONCHOSPASM Contraction of the small (genes) in the nucleus of the cell. There are 23
muscle around the bronchi. pairs of chromosomes in the human.
Glossary 629
CILIA Hairlike structures on the mucous mem- DILATION (sometimes spelt as dilatation)
brane lining the lung. Increase in the size of blood vessels, tubes, or
CILIATED CELLS Cells whose outer layer body openings.
has small hairlike projections. DILATATION See dilation.
CILIARY ESCALATOR The coordinated DIURNAL A cycle that repeats once a day, such
beating of the cilia lining the airways that as cortisol secretion or pulmonary function.
moves mucus that contains foreign material DIURNAL VARIATION The difference in
upward to the throat and out of the lungs. change between the highest and lowest points
CNS Central nervous system. of a daily cycle.
CORTISOL A hormone produced by the adre- DPI Dry powder inhaler.
nal gland which has many actions, including DUST MITES Minute creatures, not visible
potent anti-inflammatory actions. Many syn- with the naked eye, that live off the dander
thetic derivatives are used in asthma treatment. shed by the human skin. They are potent
COLD Chronic obstructive lung disease. See allergens and cause much asthma. They need
COPD. warmth and high humidity to thrive and are
CONJUNCTIVITIS Inflammation of the found in bedding and rugs.
membrane (conjunctiva) covering the eye. DYSPHONIA Hoarseness or abnormality in
COPD Chronic obstructive pulmonary disease. the voice.
Also known as COLD. DYSPNEA Shortness of breath or difficulty in
CROUP A viral infection of the larynx and tra- breathing.
chea occurring most often in the age range ECZEMA (atopic dermatitis) An allergic dis-
from 6 months to 3 years. order of the skin initially causing itch, red-
CYSTIC FIBROSIS (CF) A genetic disease ness, small blisters, swelling, and weeping,
mainly affecting the lungs and pancreas followed in time by crusting, scaling, thicken-
in which the mucus is very thick leading to ing (lichenification). The term is also used to
chronic cough and frequent chest infections. describe contact dermatitis.
Individuals with CF may wheeze. EIA Exercise-induced asthma.
CYTOKINE Protein of low molecular weight EIB Exercise-induced bronchospasm.
which regulates the intensity and duration of EDEMA Excessive fluid in tissues, producing
immunological reactions. Cytokines are pro- swelling.
duced by many cell types, including macro- EMPHYSEMA Changes in the lung seen in
phages, T and B lymphocytes, endothelial COPD with destruction of alveoli and increase
cells, and fibroblasts to mention a few. in rigidity and decreased or absent response to
CYTOTOXIC Refers to the damage or killing inhaled bronchodilators.
of tissue cells. ENDOTYPE A subgroup of a phenotype that
DANDER Dandruff or scales of skin or hair pertains to the specific type of asthma
from animals which acts as an allergen. EOSINOPHILS White blood cells that increase
DEGRANULATION The process in which with allergies.
mast cells release granules of histamine and EPHEDRINE An adrenergic substance used as
other mediators of inflammation. an oral bronchodilator. It is moderately effec-
DERMATITIS Inflammation of the skin tive but has potent CNS stimulant effects. It
marked by redness, itching, and pain. is found in many over the counter products
DIABETES MELLITUS A complex chronic because of this latter property and also as an
metabolic disorder caused by absolute or rela- appetite suppressant.
tive failure of the pancreas to produce sufficient EPIGLOTTIS Cartilage-like structure that cov-
insulin and resulting in increased glucose con- ers the windpipe when swallowing to prevent
centration in the blood and other abnormalities. food from entering it.
DIAPHRAGM The main muscle used for EPINEPHRINE (also known as adrenaline) A
breathing. It is a dome-shaped muscle that hormone formed in the adrenal medulla which
separates the chest from the abdominal cavity. increases the speed and force of the heartbeat,
630 Glossary
relaxes airway smooth muscle, and narrows HPA The hypothalamic pituitary adrenal axis
blood vessels (vasoconstrictors). which regulates cortisol secretion.
EPISTAXIS Nose bleed HYDROCORTISONE Principal secretory
EPITHELIAL Pertaining to the epithelium. product of the adrenal cortex which is anti-
EPITHELIUM The lining of both the internal inflammatory, among other actions.
and external surfaces of the body, including HYPERSECRETORY Producing too much in
the blood vessels, organs, and the skin. the way of secretions.
ESOPHAGEAL REFLUX Regurgitation of HYPERTROPHY Increase in organ size due to
food from the stomach into the esophagus increase in cell size.
(gullet). See also gastroesophageal reflux. HYPERVENTILATION An increased rate and
ESOPHAGUS Gullet. The muscular canal that depth of breathing, in excess of that required
connects the mouth to the stomach. for oxygen needs of the body.
ETHMOID Bones at the base of the skull that HYPOXEMIA Decreased oxygenation of the
make up the walls of the upper part of the blood.
nasal cavity. IATROGENIC Caused by medical treatment or
ETIOLOGY Study or description of factors diagnostic procedures.
involved in the development of a disease. ICS Inhaled corticosteroids.
EXTRINSIC In asthma, an allergic form of asthma. ICU Intensive care unit.
FEV1 Forced expiratory volume in 1 second. IDIOPATHIC Without a known cause.
Used in measurement of airflow. IGE Immunoglobulin E. High levels of IgE are
FLEXURAL ECZEMA Eczema involving the associated with many forms of allergy. See
flexural areas of the arms (inside the elbows) immunoglobulins.
and of the legs (behind the knees). IL-1 Interleukin-1. A cytokine from mononu-
FVC Forced vital capacity. Used in measure- clear phagocytic cells which promotes growth
ment of airflow. of T-helper cells and the growth and matura-
GANGLIA Collection of nerve cells outside the tion of B cells.
central nervous system. IM Intramuscular referring to an injection into
GENOTYPE Your genetic composition. a muscle.
GER Gastroesophageal reflux. See esophageal IMMUNOGLOBULIN Antibody. Protein
reflux. molecules formed by the immune system in
GERD Gastroesophageal reflux disease, when response to substances deemed foreign, that
regurgitation is associated with heart burn or is, antigens. There are five classes: IgA,
other complications such as aspiration of food IgD, IgE, IgG, and IgM, all of which have
into the lungs. diverse functions, mostly protective but
GINA Global Initiative for Asthma (a sometimes harmful, e.g., in autoimmune
publication). disorders.
GOBLET CELL A special cell that releases INFLAMMATION The body’s response to
mucus in the lining of the respiratory tract. injury or irritation. Signs include redness,
GULLET See esophagus. heat, swelling, pain, and decrease in or loss
HCP Healthcare professional. of function.
HFA Hydrofluoroalkane. A propellant used in INHALER A medical device where medica-
inhalers. tion is inhaled through the mouth and into the
HOLISTIC Having to do with the whole person lungs.
but usually referring to a system of alternative INTERCOSTAL Pertaining to the space
medicine. between the ribs.
HOMEOSTATIC The relative constant state INTRINSIC An old term used to describe a
which exists within the human body and nonallergenic form of asthma that usually
which is maintained by constant unconscious begins later in life.
involuntary changes in breathing, tempera- LABA Long-acting beta-agonist.
ture, blood pressure, and so on. LAMA Long-acting muscarinic agent.
Glossary 631
LARYNGEAL WEB Membrane found in the MUCOCILIARY ESCALATOR The wave-

larynx, usually congenital and causing severe like movement of the cilia in moving mucus
obstruction to breathing. containing foreign material (e.g., bacteria)
LARYNGOMALACIA Softness of the car- upward and out of the lungs.
tilage around the larynx, principally the MUCOLYTIC That which thins the mucus.
epiglottis. Occurs in infants as a congenital MUCOSA Mucous membrane.
anomaly. There is usually a loud noise on MYOPATHY A disorder of muscles resulting
inspiration and is generally gone by age 3 at in weakness, wasting, and a change in the
the latest. muscle cells.
LARYNX The voice box, placed between the NARES Nostrils.
throat and the trachea. NEBULIZER A device that uses compressed
LEUKEMIA A malignant disease with prolif- air or oxygen to aerolize a solution for pur-
eration of white cells. poses of inhalation.
LEUKOCYTE A white blood cell. NORADRENALIN See norepinephrine.
LEUKOTRIENES A product of arachidonic NOREPINEPHRINE A hormone released
acid that is a mediator of inflammation. by the adrenal medulla that is a powerful
LIPID A fat or fatlike substance in tissue. vasoconstrictor.
LOBAR Pertaining to the lobe. NSAIDS Nonsteroidal anti-inflammatory drugs.
LOBE A semidetached portion of an organ such OBSTRUCTIVE SLEEP APNEA
as the lung, brain, or liver. (OSA) Cessation of breathing during sleep
LOBULE A small lobe. of more than 10 seconds usually associated
LTRA Leukotriene receptor antagonist. with loud snoring. Commonly found in obese
Medication that blocks the receptors to which persons. Note that nasal narrowing, e.g., due
leukotrienes bind. to allergy, can also cause OSA or can make
LUMEN The channel or cavity within the air- it worse.
way or blood vessel. OCS oral corticosteroids
LYMPHOCYTES A type of white blood cell OLFACTORY Pertaining to the sense of smell.
formed in the lymphatic system throughout ORAL ALLERGY SYNDROME Condition
the body. They are divided into two major that occurs in some individuals who are aller-
groups B cells and T cells and have numerous gic to inhaled pollens, usually with seasonal
immunologic functions. allergic rhinitis. These persons develop con-
MACROPHAGE A cell that surrounds and current allergies to fresh fruit and raw vege-
digests foreign substances in the body. tables. They complain of itching and swelling
MAST CELL A cell that is morphologically of the lips, tongue, and palate. Some associa-
similar to basophils but are found in tissue. tions are known such as birch with apples,
Mast cells contain histamine and heparin and grass with potato, and ragweed with melons
are major players in allergic reactions since and bananas.
IgE antibodies bind to their surface. OROPHARYNX Area of the mouth containing
MAXILLARY SINUS Pair of large air spaces the tonsils.
forming cavities in the front of the face under OSA See obstructive sleep apnea.
the eyes. OSTIA Openings, as in the sinuses.
MCG Microgram. One millionth of a gram. PAF Platelet-activating factor is a lipid-derived
MDI Metered dose inhaler. product produced by many cells. It causes
MG Milligram. One thousandth of a gram. smooth muscle contraction, attracts and
MONILIASIS See candidiasis. stimulates eosinophils, and is associated with
MONOCYTE A large white blood cell with increased bronchial reactivity at least in ani-
phagocytic activity. mals. Its role in human asthma is unclear.
MORBIDITY An illness or abnormal condi- PALATE The roof of the mouth.
tion that affects a person. PARASYMPATHETIC SYSTEM Part of the
MORTALITY Relating to death. autonomic nervous system.
632 Glossary
PARASYMPATHOMIMETIC Substances RECEPTOR A specialized area on the cell sur-

that cause the same effect as those that affect face or in the cytoplasm which binds to spe-
the parasympathetic nerves. cific substances in the surrounding fluid and
PATHOGENESIS Mode of development of promotes a pharmacologic effect in the cell.
disease. In asthma the adrenergic receptors are very
PEF Peak expiratory flow. Measure of a per- important, and they are found in many tissues.
son’s ability to exhale. Usually written with There are three classes of receptors, alpha
the word rate added behind it to give PEFR. (a or α), beta-1 (b1 or β1), and beta-2 (b2 or
PEFR See PEF. β2). Different kinds of receptors are found in
PFA Potentially fatal asthma. different tissues.Drugs vary in their receptor
PH A scale showing how acidic or alkaline a specificity—i.e., in the kinds of receptors they
solution is. stimulate. Stimulation of the alpha receptors
PHAGOCYTOSIS Process of ingestion and leads to constriction of the skin vessels of the
digestion by certain blood cells of solid sub- skin and the gut. Stimulation of the beta-1
stances, e.g., foreign particles, other cells, and receptors leads to an increase in the rate and
bacteria. force of the heartbeat. Stimulation of beta-2
PHARMACOLOGICAL Referring to the receptors leads to relaxation of bronchial
study of the uses and actions of medications. smooth muscle and dilatation of blood ves-
PHARYNX The throat. sels of skeletal vessels. Modern adrenergic
PHENOTYPE The type of individual one agonist medications such as albuterol have
becomes as a result of the interaction of one’s been designed to be highly selective for beta-2
genes and one’s environment. receptors.
PHRENIC NERVE The nerve which passes REM Rapid eye movement, a phase of sleep.
from the spinal cord to the diaphragm and RESPIRATORY TRACT The complex of
stimulates it to move. organs and structures that are involved in
PLETHYSMOGRAPH Equipment used to breathing and exchanging oxygen from the air
measure changes in lung volumes and airway outside with carbon dioxide in the blood.
resistance. RHINITIS Inflammation of nasal mucous
pMDI Pressurized metered dose inhaler. See membranes.
MDI. RSV Respiratory syncytial virus, common at all
POLYP Small growth on the surface of a ages, which causes severe lung infection in
mucous membrane. babies, many of whom have recurrent wheez-
POSTERIOR NARES The back of the ing. May trigger an attack in persons with
nasal cavity, immediately in front of the asthma.
choanae. SALBUTAMOL A beta-2 adrenergic stimulant
PRN Pro re nata. Take as required. used to treat bronchospasm. Also known as
PROPHYLACTIC Medication taken to pre- albuterol.
vent occurrence of disease episodes. SEPTUM Dividing wall between cavities.
PROSTAGLANDIN D2 A strong hormonelike SEROUS CELLS Cells that line the walls of
fatty acid that acts on certain organs. body cavities and release a watery fluid.
PRURITIS The symptom of itching. SINUSES Openings or cavities in the body of
PSYCHOTROPIC Having an effect on the the upper jaw, they include the maxillary, the
mind. frontal, the ethmoidal, and the sphenoid and
PULMONARY Referring to the lungs or respi- are lined with mucous membranes.
ratory system. SOMATIC In general, concerning the body, but
PVC Polyvinyl chloride. used to describe the part of the nervous sys-
QD Quaque die. Once daily. tem that deals with skeletal muscle which is
QID Quater in die. Four times a day. largely voluntary in contrast to the involuntary
QOD Quaque altera die. Every other day autonomic system.
QOL Quality of life. SPHENOID Bone at the base of the skull.
Glossary 633
SPIROMETRY A test that measures and tion from B cells. There is a balance between
records the volume and flow rate of inhaled TH1 and TH2. Atopic individuals have a pre-
and exhaled air. dominant TH2 response.
STEROID A chemical description of a variety THORAX Chest cavity.
of substances, usually refers to corticoste- THRUSH See candidiasis.
roids, a hormone essential for life (see cortico- TID Ter in die. Three times a day.
steroid). Confusion arises as the term is used TRACHEA Windpipe. It is between the larynx
in the media as if it only referred to androgens and the bronchi.
(male sex hormones). TRACHEAL STENOSIS Narrowing of the
STRIDOR Abnormal, high-pitched breathing trachea.
sound caused by narrowing in the upper air- TRACHEA-BRONCHIAL TREE The com-
way (above carina). Occurs when breathing in plex of structures that includes the trachea, the
when the problem is outside the thorax, i.e., bronchi, and the smaller airways of the lungs,
larynx or upper part of trachea; occurs when whose function are to provide pulmonary
breathing in and out when the problem is in ventilation.
the part of the trachea inside the thorax. TRACHEOMALACIA Softening of the carti-
SYMPATHETIC OR EXCITATORY SYSTEM lage of the trachea.
Part of the autonomic nervous system. TRIGGER When used of asthma, anything that
SYMPATHOMIMETIC AMINES Medication precipitates an episode of asthma.
that acts like the sympathetic nervous system TURBINATES Bony projections within the
to relax smooth muscle. nose that are covered with mucous membranes
TACHYCARDIA Rapid heartbeat. and are an important part of body defenses.
TACHYPNEA Abnormal rapid rate of UAO Upper airway obstruction.
breathing. URI Upper respiratory infection.
TARTRAZINE An artificial coloring agent URTICARIA A skin eruption marked by
known to causes problems for those with asthma. wheals of differing shapes and sizes with clear
T CELLS Cells from bone marrow that develop margins and pale centers—also called hives.
an antigen-specific receptor. They are special- VAGUS NERVE The longest cranial nerve,
ized lymphocytes that secrete cytokines that essential for many functions of the body.
govern an immune response. Helper T cells, VASOCONSTRICTION Opposite of
TH1 and TH2 are important in asthma. TH1 is vasodilation.
common in persons without asthma and TH2, VASCULAR RING A congenital anomaly in
which promotes IgE production, in those with which arteries leaving the heart surrounds
asthma. and/or compress the trachea causing difficulty
TENDON Fibrous band of tissue that attaches in breathing and stridor.
muscle to bone. VASODILATION Widening or enlarging of
TERBUTALINE A beta-adrenergic medi- blood vessels. Also spelt as vasodilatation.
cation similar to albuterol, used to relieve VASODILATATION See vasodilation.
bronchospasm. VASOVAGAL Also known as a faint. There is
TERMINAL RESPIRATORY UNIT Air sacs sudden loss of consciousness due to lack of
at the end of the bronchial tree. blood flow to the brain resulting from reduced
TH1 AND TH2 CELLS The THI and TH2 blood release by the heart together with wid-
paradigm. Uncommitted T-helper cells, upon ening of blood vessels around the heart and a
stimulation with certain cytokines, polar- reduced heart rate.
ize to a TH1 or TH2 phenotype. TH1 pro- VCD Vocal cord dysfunction.
file is consistent with a nonatopic immune VERTEBRAE The 33 bones that constitute the
response.TH1 cells produce IFN-γ (interferon spinal column.
gamma) which inhibits IgE production. TH2 WHEEZE Audible sound produced when air is
cells produce Il-4 and Il-13 (interleukins), inhaled or exhaled with high velocity through
which are potent stimulators of IgE produc- narrowed air passages.
Index
A Adults
Absence from school, 10 concerns, 522
Acaricide, 149 counseling, 396
Accolate, 201 factors in dealing with, 496–497
ACE inhibitors, 146, 147, 264, 322 learning needs, 524
Acetylcholine, 45, 185, 274, 625, 626 low-literacy, 525
Acetylsalicylic acid (ASA), 144–146, 277, 626 Advair, 186, 202, 229, 355
Acne, 182, 183, 382, 454 Adventitia, 43
Action plan, 24, 31, 107, 117, 315, 337, 340, 341, Adverse reactions, 191, 456
343, 344, 355–360, 364, 391, 394, 400, Aeroallergen, 138, 157
404, 407, 461, 464, 503, 508, 531, 541, Aerochamber, 233–235
542, 574, 584, 588 Aerolizer, 178, 236–237
sample plans, 548–549 Affective domain
Acupuncture, 22, 273, 297, 423–426, 431–432 and chronic illness, 539–540
consensus statement, 431 planning for, 544
Acute See also Domains
deterioration, 119, 311, 348, 354 Age-related
respiratory induced changes in, 310 asthma, 121–123
Adapt, 32, 263, 374–376, 379, 384, 396, 477, 483, 497, management problems, 122
539, 540, 544, 555, 559, 569, 577, 612 Age-related learning, 495–501
Adaptation, 32, 47, 377, 394, 396, 480, 522, 528, Agonist, 274
540–542 Air pollution, 19, 69, 106, 133, 139, 157, 264, 312, 382
Adenosine 5’ Monophosphate (AMP), 79, 83 Air quality, 139, 531, 585–587
Adherence Airway
avoidance of triggers, 375 asymmetrical, 42, 52
common issues, 372 generations, 45
cultural factors, 373 histology, 43–44
definition, 385–386 hyperresponsiveness, 8, 18, 19, 21, 52, 54, 82, 184,
family issues, 378 206, 265, 296, 297
general approach, 392–398 turbulence, 41, 42
HCP adherence, 386 Albumen, 44, 153
specific aids to, 398–401 Albuterol, 70, 71, 80, 82, 113, 126, 157, 158, 180, 185,
strategies, 378 198, 199, 204, 229, 234, 239, 240, 247, 258,
Adolescents 316, 317, 355, 560, 612, 616, 619–623, 625
concerns, 522–523 Aldehyde, 163
counseling, 395–396 Allergen, see Under specific allergens (indoor, outdoor,
independence, 520 cockroach, dust mite, etc.)
non-adherence, 522 Allergen proof, 149, 150, 152
peer pressure, 520–521 Allergic asthma, 15, 23, 135, 140, 197, 213, 295
rebellion, 520 Allergic bronchopulmonary aspergillosis (ABPA), 22,
teaching approach, 521–522 135, 307
Adrenal, 184, 194, 196, 264 Allergic rhinitis, 17, 40, 41, 49, 50, 81, 114, 115, 142,
suppression, 182, 184, 185, 194, 321 158, 190, 261, 262, 293–299, 307
Adrenaline, 114, 322, 323, 625 Allergic salute, 100, 294, 462
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature 635
Switzerland AG 2021
I. Mitchell, G. Govias, Asthma Education, https://doi.org/10.1007/978-3-030-77896-5
636 Index
Allergy Aortic bodies, 47

allergy control, 150, 154 Apnea, 47, 626;
products, 15 See also Obstructive sleep apnea
resources, 153–154 Applications, 498, 499, 530–532
shots, 197–206, 453, 463 Apps, 530–534, 551, 558
Allopathic, 438 mobile, 533, 534
Alpha-1 antitrypsin, 46 ArmonAir, 200, 239, 530
Alternaria, 115, 134, 135, 148, 364 Arnuity Ellipta, 200
Alternate diagnosis, 362 Aromatherapy, 297, 424, 426, 434, 438
Alternate medicine, see Complementary and alternate Arterioles, 43
medicine Arthritis, 188, 243, 249, 262, 264
Alveolar ASA desensitization, 277
ducts, 42, 57, 625 Asian ladybugs (ALB), 137
sac, 42, 57, 625 Asmanex, 200, 229
Alveoli, 40–43, 52, 57, 78, 83, 102, 124, 192, 555, 625 Aspergillosis, 135, 307
Alvesco, 200, 229 Aspergillus, 134, 135, 148, 307, 626
Aminophylline, 195, 202 Aspirate, 300
Analgesics, 281, 282, 347 Aspirin, 98, 144–147, 259, 263, 277, 278, 282, 283, 295,
Anaphylactoid, 319, 322, 625 298, 347, 434, 465
Anaphylaxis Aspirin sensitivity, 113, 144, 277–278
causes, 319–320 Assessing
definition, 318–319 environment, 582–584
differential diagnosis, 322 home, 584–585
epinephrine injector, 323, 324 Asthma
exercise-induced, 319 action plan, 24, 31, 107, 117, 315, 337, 340, 341,
iatrogenic, 320 343, 344, 355–360, 364, 391, 394, 400, 404,
management, 322–323 407, 461, 464, 503, 508, 531, 541, 542, 574,
patient education, 323–324 584, 588
reaction-biphasic, 323 acute, 6, 51, 52, 60, 64, 101, 102, 110, 116–117, 135,
risk factors, 321 178–180, 183, 197, 231, 245, 258, 264,
symptoms, 321 310–317, 360, 376, 386, 428, 574, 581
treatment, 321 age-related, 121–123
Anesthesia, 83, 138, 256, 265–266, 320 allergic asthma, 15, 23, 135, 140, 197, 213, 295
Angioedema, 137, 138, 142, 143, 277, 278, 321, 625 alternate diagnoses, 301
hereditary, 322 assessment, 190, 581
Angiotensin converting enzyme (ACE), 123, 146, 147, and the athlete, 158
264, 322 brittle, 117, 318, 351, 354, 362, 380
Animal emanations, 133 catastrophic, 117
Antacids, 281, 282, 301, 302 control, 183–196
Antagonist, 46, 185, 197, 265, 271, 279, 301, 440 death, 11, 313, 381, 389, 453, 569, 596
Antibiotics, 147, 183, 196, 197, 259, 267, 320, 389, 471 death, fear of, 119
Antibody, 46, 188–191, 197, 284 definition, 7
Anticholinergic, 22, 179, 181, 185, 186, 201, 227, 264, depression, 310, 362, 363
296, 317, 456 diagnosis, 125, 194, 212, 267
Anticipatory guidance, 19, 275, 345, 394–396, 398, 506, diary, 431, 517, 541, 556
547, 570; epidemic, 134
See also Counseling etiology, 15
Antigen, 18, 19, 49, 188, 197, 261, 307, 321, 625 exercise-induced, 113
Antigen avoidance diet, 19 failure of management, 11
Antihistamines functional impairment, 383
adverse effects, 279–280 gender, 124
excipients, 280 genetic factors, 16, 62
Antitussives, 281 home assessment, 159–161
Anxiety, 5, 11, 24, 47, 119, 125, 126, 186, 188, 191, 204, impact of, 376–378
208, 282, 303, 309, 310, 321, 323, 361–363, life-threatening, 116–117
374, 376, 379–384, 386, 392, 396–398, 401, medications (see Medications to treat)
403, 405–407, 426, 433, 435, 437, 470, monitoring, 126–127
505–508, 516, 522, 523, 527, 528, 547–549, mortality, 11, 186, 313, 382, 569
552, 562, 591 nocturnal, 114–115
Aorta, 40, 42, 43, 45, 47 non-allergic, 15
Index 637
occupational (see Occupational asthma) Asthma educator

pathophysiology, 30, 50–54, 77, 393 essential qualities, 31–32
patterns of, 109–116, 477 role, 29
potentially fatal, 309, 363–364, 630 skills, 30–31
psychiatric morbidity, 10, 362, 380 Asthma severity, see Severity
recognition of deterioration, 375, 390, 400 Atelectasis, 42, 103, 112, 312, 314, 437
referral to a specialist, 127–128 Athlete
seasonal changes, 115 competitive, 113, 158, 276–277
severe asthma, 9–12, 24, 25, 52, 77, 83, 104–106, Olympic athletes, 158
112–114, 128, 183, 190–194, 196, 205, 206, Atopic
208, 209, 211, 231, 258–260, 266, 269, 277, dermatitis, 15, 108, 115, 122, 140, 212, 261, 293, 627
295, 299–301, 312, 313, 317, 318, 347, 350, disease, 21, 261, 338
354, 362, 363, 383, 384, 425, 429, 447, 449, 450, disorders, 99
458, 463–465, 470, 519, 528, 554, 571, 592, 596 syndrome, 293
sex differences, 124 Atopy, 15, 16, 18, 19, 21, 24, 53, 54, 77, 140, 262,
significance, 8–15 269–271, 279, 316, 321
symptoms, 7, 22, 82, 84, 113, 114, 121, 135, Atrium, 42, 43
137–140, 144, 150, 156, 159–161, 193, 194, Atrovent, 181, 201, 296
205, 206, 257, 260, 268, 270, 278, 300, 304, Auscultation, 80, 102, 103, 116, 310, 312
339, 344, 363, 376, 403, 404, 446–449, 452, Autoinjector, 153, 203, 320, 322–324
456, 461, 464, 465, 468, 503, 516, 519, 520, Automated, 574
529, 548, 549, 582, 586, 593, 602, 613 Autonomic, 45, 48, 51, 426, 427
treatment, 21, 118, 119, 197, 209–211, 250, 256, 310, Ayurvedic, 425
362, 372, 393, 439, 520, 523, 528, 548
uncontrolled, 9, 10, 12–14, 75, 105, 186, 194, 215,
216, 259, 260, 304, 465, 531, 560, 613 B
Asthma Action Plan (AAP), 24, 31, 107, 117, 211, 315, Baking soda, 156, 297, 298
337, 340–341, 344, 352, 355–362, 364, 391, BAL, see Bronchoalveolar lavage
394, 400, 404, 407, 461, 464, 503, 508, 531, Barriers to learning
541, 542, 561, 572, 574, 584, 588 emotional factors, 504–506
Asthma clinic environment, 501–502
asthma educator, 569 individual factors, 502–504
competency, 528–530 physical factors, 502
confidentiality, 597 sociological, 504–506
costs, 579 Basement membrane, 43, 53, 181, 626
data analysis, 594–595 Beclomethasone, 184, 199, 200, 204, 229, 234, 296, 458
data collection, 579 Behavior, 10, 29, 30, 97, 187, 188, 195, 272, 273, 310,
data evaluation, 577–578 354, 362, 370, 371, 374, 376–379, 381–383,
equipment and materials, 570–572 385, 387–389, 392, 397, 400–403, 406–409,
essential qualities, 591 414, 469, 477, 479–486, 493, 495, 497, 501,
facilities, 570 504, 509, 515, 517, 524, 525, 532, 537, 539,
knowledge, 588 540, 542, 543, 545, 550, 555, 558, 573, 576,
management ability, 569, 591 592, 593, 595, 597–599, 601
operation, 591 Behaviorism, 478–482
organizational ability, 580, 581 Beliefs
patient relationships, 574 cultural, 529
personal attributes, 602 health, 373, 403, 407, 504, 505, 526, 529, 543
plan, 578–579 religious, 408, 463, 543
professional growth, 602 Benralizumab, 189, 190, 203
resources, 575–577 Benzoate, 142, 149, 280, 319, 320
responsibilities, 594 Beta adrenergic blocking agents, 264
review, 595–597 Beta agonist, see Agonist
role of, 587 Beta blockers, 98, 146, 147, 191, 263, 282
running an, 569 Biocidal, 267
skills, 577, 578 Biofeedback, 273, 426–428
standards, 579–582 Biological changes
team relationships, 601–602 menses, 159
treatment in, 574 pregnancy (see Pregnancy)
Asthma control test (ACT), 215, 531, 575 Biologics, 9, 180, 188, 190–193, 213
Asthma COPD overlap (ACO), 262, 265, 304–305, 625 Biphasic reaction, 321–323
638 Index
Birch, 134, 142, 432 CAM

Birth control pills, 154, 181, 464, 471 professions, 423
Black box, 187, 188, 191, 296 self-help, 434–438
Bleach, 140, 148, 156, 278 See also Complementary and alternate medicine
Blood gases, 47, 306, 312, 314 Camp, 347, 394, 463–464, 518, 547, 578, 612
Body mass index (BMI) Candidiasis, 264, 626
calculation, 269 Candles, 140, 439
and obesity, 269 Cannabis, 140, 439
Body position, 69–70 Capillaries, 42, 43, 52, 321
Boric acid, 151 Capsule, 202, 204, 236, 237, 280, 390, 408, 435–437
Bowen technique, 424, 434, 440 Carbon dioxide, 42, 47, 52, 78, 81, 314, 428, 463
Bradycardia, 314, 316, 322, 626 Carbon footprint, 225
Breast feeding, 19, 617, 618 Carbon monoxide (CO), 57, 60, 139, 160, 192
Breathing Cardiac arrest signs, 318
dysfunctional, 125, 426 Cardinal symptoms, 97, 125
exercises, 360, 361, 423, 428 Cardiopulmonary resuscitation, 318
expiration, 303, 311 Cardiovascular, 102, 123, 180, 205, 262–264, 269, 270,
inspiration, 311 277, 281, 282, 296, 305, 306, 312, 320, 321,
muscles of, 44 364, 427, 437
noisy, 7, 118, 405 Carina, 41, 42, 626
Breath sounds, 102, 116, 312 Carotid body, 47, 626
Brittle asthma, see Asthma Case study, 119, 122, 155, 163, 294, 320, 347, 349, 355,
Bronchial challenge, 17, 79–83 364, 391, 414, 439, 501, 612–623
Bronchial obstruction, 119, 190, 276 Cat, 17, 115, 136, 137, 150–152, 155, 383, 450, 451,
Bronchial sounds, 102 466, 586, 621, 622
Bronchial thermoplasty, 23, 193, 206–207 Cataract, 264
Bronchiectasis, 262, 307, 308 Catastrophic asthma, 117
Bronchioles, 42–44, 57, 124, 313 Cells
Bronchiolitis, 112, 118, 121, 122 basophils, 46, 50
Bronchitis, 17, 81, 97, 112, 197, 496, 497, 626 B cells, 49
Bronchoalveolar lavage (BAL), 83–84, 104 clara, 44
Bronchoconstriction, 71, 81, 83, 126, 143, 144, 157, 181, dendritic, 49
196, 208, 230, 270, 276, 277, 279, 300, 308, eosinophils, 7
321, 349, 375, 402 lymphocytes, 49, 299
Bronchoconstrictor, 277 macrophages, 49
Bronchodilation, 46, 81, 186, 226 mast, 7, 46, 49, 50, 83, 181, 195, 321, 629
Bronchodilators monocytes, 629
anticholinergic, 179, 181 myofibroblast, 53
cromolyn sodium, 196–197 neutrophils, 7, 50, 83, 113
leukotriene inhibitors, 179, 186 (see also phagocytic, 49
Leukotrienes) serous, 44, 630
long-acting, 179, 301 T cells, 49, 631
nedocromil, 196–197 Cervical, 44, 45, 298, 430
short-acting, 181 Chamomile, 142, 147, 319
theophylline, 195–196 Chemical odors, 133
Bronchopulmonary dysplasia, 121, 122, 626 Chemoreceptors, 47, 48, 257
Bronchospasm, 46, 51, 69, 79, 113, 118, 208, 264, 266, Chemotaxis, 50, 277
270, 276, 277, 279, 321, 437, 626 Chest pain, 5, 6, 97, 118, 119, 163, 262, 300, 301, 303,
Bronchus intermedius, 42 307, 321, 517
Bruising, 182 Chest wall, 6, 44, 45, 47, 48, 261, 268
Bruner, 487, 488, 493, 494 deformity, 101
Budesonide, 183, 184, 186, 200, 203, 204, 213, 229, 242, Chest x-ray, 103, 122, 192, 304, 314, 614
243, 247, 258, 296, 356 Chiropractic, 423–426, 429–430, 433
Buteyko, 360, 428 Chronic
angioedema, 322
urticaria, 322
C Ciclesonide, 185, 200, 204, 229, 296
Calculating Cilia, 43, 48, 139, 162, 627
diurnal variability, 75, 87, 351–352 Ciliary clearance, 262
reversibility, 74–75 Ciliary escalator, 44, 627
Index 639
Cinquair, 189, 191 533, 534, 539, 543, 547, 548, 553, 556, 557,
Cladosporium, 134, 135, 148 559, 570, 575, 576, 580, 583, 584, 588, 617,
Classical, 535 619, 621
Classification of Conchae, 40
control, 209 Concordance, 371
exacerbation, 22, 111, 314 Confidentiality, 344, 521, 527, 574, 597
severity after treatment, 209–211 Congenital, 100, 299
severity before treatment, 107–108 Congestive heart failure, 81, 118, 123, 262
Climate (weather), 134 Consultation, 97, 153, 158, 187, 344, 354, 364, 384,
Clubbing, 99, 100, 308 414, 425, 426, 432, 527, 544, 549–550, 561,
Cockroach, 135, 137, 151, 160, 295, 382, 383, 504, 517, 574, 584
583–586 Contact dermatitis, 278, 292–293
Codeine, 281, 320, 465 Contemplation, 272, 273
Cognition, 378, 482, 537 Controller, 9, 25, 47, 105, 186, 201, 204, 205, 207, 209,
Cognitive, 10, 86, 139, 249, 269, 294, 295, 306, 373, 257, 311, 316, 340, 350, 379, 390, 454–456,
383, 384, 397, 401, 482, 483, 485, 487, 488, 497, 531, 538, 544, 548, 555, 595, 596
493, 501, 520, 523, 524, 527, 537, 538, 544, Control of breathing, 47–48, 257, 361, 380
548, 549, 558, 575 COPD, 17, 77, 80, 81, 117, 118, 123, 128, 161, 181, 185,
Cognitive domain 195, 262, 263, 304, 305, 348, 364, 627
planning for, 545 Coping
See also Domains methods of, 379, 383, 407
Cognitive theory of learning, 481–484 strategies, 7, 378–381, 383, 397
Cohesion, 376, 384 Coronovirus, 5, 24–26, 97, 140, 156, 270, 272, 373, 375,
Colchicine, 206 409, 470, 490, 491, 574, 575
Cold air, 6, 19, 48, 82–83, 115, 143, 144, 156, 157, Corticosteroids
303, 451 inhaled, 9, 17, 22–24, 105, 110, 115, 117, 158, 179,
testing, 82 183–185, 187–190, 194, 197, 204, 209, 257,
Collaborative, 490, 530, 550 258, 264, 265, 270–272, 277, 299, 301, 308,
Collagen, 53 362, 371, 381, 385–387, 390, 399, 425, 439,
Colophony, 267 440, 455–458, 460, 481, 524, 593, 613–621,
Combination medications, 224 623, 628
Combustion, 160 side effects, 182
Common errors systemic, 182, 183
DPI, 236 Cortisol, 114, 181, 182, 427, 455, 457, 458, 627
MDI, 229 Costs
Communication, 30, 31, 217, 338, 353, 386–388, 392, of asthma, 13, 14
393, 395, 396, 404, 405, 409, 412, 414, 438, of therapy, 104
488, 490, 525, 526, 530, 534, 543, 544, 547, Cough, 5, 6, 18, 41, 48, 49, 51, 66, 67, 84, 97–99, 105,
549–551, 553, 556, 561, 580, 581, 592, 595, 109–111, 113, 118–120, 123, 125, 137, 138,
597, 598 163, 260, 262, 264, 267, 270, 277, 281, 282,
Comorbid, 214, 262, 309, 364, 575 298, 300, 302, 303, 305–307, 311, 315, 321,
Competitive athletes, 113, 158, 276–277, 281 322, 339, 346, 354, 423, 435, 446, 448, 449,
Complementary and alternate medicine 451, 456, 457, 470, 529, 586, 592, 612–614,
approach of the educator, 438–440 620, 621
definition, 423 Cough syrup, 260, 457, 612, 613, 620, 621
evaluation of, 425 Counseling
prevalence, 159 adolescents, 395–396
reasons for use, 423 adults, 396
risks, 425 anticipatory guidance, 394
self-help, 426 crisis management, 397 (see also Anticipatory
Compliance, 312, 371, 373, 386, 408, 504, 506, 521, guidance)
522, 573, 581; long-term, 394–396
See also Adherence parents, 394–395
Components of examination, 102–103 short-term, 394
Computer-assisted learning, 489–490, Covid 19, 5, 24–26, 97, 140, 156, 270, 272, 373, 375,
573 409, 471, 490, 491, 574, 575
Concerns, 24, 30–32, 186, 188, 190, 191, 208, 216, 257, CPR, see Cardiopulmonary resuscitation
272, 283, 321, 337, 338, 341–345, 392, 395, Crackles, 102, 312
405, 446, 464, 470, 482, 484, 492, 497, 502, Crepitus, 101
504, 506, 507, 517, 518, 520, 523, 524, 527, Criteria for acceptability, 68–70
640 Index
Cromolyn, see Intal Turbuhaler, 242–243

Cross, 41, 192, 279 Twisthaler, 241–242
Cross reactivity - pollen food, 142 Wixela Inhub, 202, 236, 244–245
Cultural competency, 528–530, 600 Dexamethasone, 201, 204
Cultural differences, 407–414 Diabetes, 26, 28, 182, 257, 262, 265, 269–271, 281, 282,
Culture, 15, 307, 403, 407–409, 412–414, 488, 500, 503, 310, 437, 457, 530, 580
505, 522, 526, 529, 530, 538, 543, 578, 600 Diagnosis
Cyanosis, 99, 116, 315 auscultation, 102
Cyclosporine, 206 avoiding delays in diagnosis, 125–126
Cystic fibrosis, 80, 81, 99, 117, 118, 121, 122, 299, palpation, 101
307, 627 percussion, 101–102
Cytokines, 49, 50, 112, 190, 269, 306, 427, 627 physical examination, 99–103
pulsus paradoxus, 102
Diagnostic problems
D five to twelve years, 123
Dampness, 19, 160, 582, 584, 586 less than one year of age, 121–122
Dander, 17, 98, 114, 135–137, 152, 155, 213, 295, 375, one to five years, 123
450, 451, 466–468, 583, 627 sixty years and above, 123
Dapsone, 206 thirty-five to sixty years, 123
Data analysis and evaluation, 594–595 twelve to twenty-five years, 123
Data collection, 339, 579, 590, 591, 594 twenty-five to thirty-five years, 123
Daycare, 18, 24, 135, 136, 144, 156, 160, 260 Diaphragm, 40, 41, 44, 45, 48, 52, 101, 102, 138, 195,
Decongestant, 259, 282, 296, 298 257, 361, 627
Defense mechanism of the lung, 43 Diarrhea, 141, 143, 163, 204, 205, 208, 277, 278,
Deformities, 101 321, 620
Dehumidifier, 148, 160 Diary, see Peak expiratory flow (PEF), diary; Symptom
Dementia, 502 diary
Denial, 11, 27, 321, 337, 346, 348, 363, 374, 375, Dietary
379–381, 384, 390, 396, 406, 504, 522, 554 factors, 270
Dental problems, 100 manipulation, 261, 436
Depression, 11, 183, 187, 188, 191, 194, 208, 212, 262, prevention, 260
263, 269, 274, 280, 282, 292, 294, 306, restriction, 142, 260, 261, 395
309–310, 320, 362–364, 376, 380–383, 392, Differential diagnosis
397, 406, 407, 410, 433, 457, 505, 523, 540 anaphylaxis, 322
Deterioration, recognition of, 375 asthma, 321
Deviated nasal septum, 297 bronchial obstruction, 119
Devices COPD, 118
accessory, 264 hyperventilation, 118–119
Aerochamber, 233 vocal cord dysfunction, 119
Aerolizer, 236–237 wheeze and lung disease, 117–118
Breo Ellipta, 203, 236 Digihaler, 240–241
Choice of, 248, 249 Digital health
choosing, 249 apps, 530
considerations in choosing, 248 services, 575
counters, 228 Dilution techniques
Digihaler, 240–241 helium, 78
Diskus, 237–238 nitrogen washout, 78
Dry Powder Inhaler, 235 Direct costs of asthma, 12
Flexhaler, 243–244 Direct to consumer, 283–284
holding chamber (see Holding chamber) Direct to consumer advertizing (DTCA), 283–284
inspiratory flow rates, 530 Disease management
Metered Dose Inhaler (MDI), 225–230 programs, 26, 581
Nebulizer, 245–247 skills, 28
peak flow meter, 71 (see also Peak expiratory Diskus, 237–238
flow (PEF)) Disturbed sleep, 6, 9, 10, 294, 360, 447
RespiClick, 239 Diurnal variation, 75, 80, 114, 120, 194, 271, 349, 350,
selecting, 249–250 354, 360, 362, 461, 627
spacers (see Spacer) calculation, 75
Spiriva Respimat, 227 Dizziness, 143, 163, 190, 204, 208, 278, 280, 282,
substitute, 247 321, 323
Index 641
Domains Electronic cigarettes (EC), see E-cigarettes

affective, 538–539 Emergency department (ED), 9, 26, 96, 97, 99, 111,
affective, and chronic illness, 539–540 181, 295, 303, 318, 394, 398, 407, 461, 592,
cognitive, 537–538 593, 621
impairment, 107 Emotion (as a trigger), 98, 144, 517
of learning, 536–537 Emotions, 15, 144, 159, 215, 409, 428, 449, 520, 521,
psychomotor, 541–542 524, 547, 555
risk, 108 Emphysema, 70, 117, 118, 123, 161, 262, 263, 304,
DPI 348, 471
common errors, 236 Endotoxins, 18
technique, 248 Endotype, 15, 188, 217
See also Devices Environment, 10, 99, 338, 412, 501–502, 582
Draper, 497 Environmental allergen, 152
Drug reactions, 282, 322 Environmental causes of asthma, 17
Dulera, 186, 203, 229 Environmental exposure, 17
Dupilumab, 189, 190, 203 Environmental issues, 17–19, 133–140
Dupixent, 189. 203 Environmental tobacco smoke (ETS), 18, 139, 155,
Dust mite, 18, 49, 135–137, 149–150, 158, 160, 180, 161, 503
213, 261, 295, 299, 382, 383, 439, 451, 452, Environment, learning, 30, 32, 484, 552
467, 534, 583, 627 Eosinophil, 50, 77
Dysfunctional breathing, 125, 426 Ephedra, 425, 433, 434
Dysmenorrhea, 159 Ephedrine, 281, 282, 434
Dysphonia, 185, 264, 278, 627 Epiglottis, 41
Dyspnea, 96, 97, 111, 118–120, 123, 125, 138, 257, 262, Epinephrine, 46, 143, 153, 155, 191, 205, 259, 281, 282,
263, 265, 301–304, 307, 308, 314–316, 321, 321–324, 463, 589
345, 361, 362, 375, 381, 390, 403, 592, 614, injectors, 155, 191, 205, 292, 323, 324, 463,
616, 627 589
Epithelium, 43, 44, 50, 53, 70, 83, 162, 181,
299
E Equivalents, 79, 225, 234, 250, 348, 413, 458
EBC, see Exhaled breath condensate Erickson, 492, 503, 524
E-cigarettes, 162, 275, 347 Ethnic, 9, 10, 23, 30, 32, 61, 62, 74, 216, 270, 382, 385,
E-cigarette Vaping use Associated Lung Injury 398, 407, 408, 411–413, 490, 503, 505, 529,
(EVALI), 163 530, 554, 588
Eczema, 15–17, 98, 103, 115, 122, 138, 140, 141, 261, Ethnicity, 9, 65, 205, 309, 349, 385, 407, 490, 502, 503,
262, 277, 282, 293, 294, 310, 462, 620 522, 539
Edema, 46, 118, 143, 257, 282, 296, 298, 311, Etiology, 15, 141, 297
321, 322 Evaluation
Education data, 594
follow-up visit, 342–344, 387, 399, 507 designing a program, 590–593
health, 12, 26, 406–407, 577 education programs, 589–590
initial visit, 337–341, 355, 399 of self, 597–602
level of, 373, 383, 500, 517, 524, 577 self-evaluation checklists, 599–602
mother's level of, 383 teaching materials, 577–578
for parents, 216 Exacerbation, 8, 11, 31, 76, 77, 99, 102, 107–109, 116,
physical, 588 127, 128, 136, 139, 141, 143, 144, 159, 163,
principles, 556 178, 183, 184, 216, 228, 249, 250, 257–260,
process of, 536–542 266, 271, 277, 296, 305, 306, 308, 312,
programs, 578 314–316, 345, 355, 360, 376, 380–382, 394,
response to, 528 398, 403, 448, 542, 545, 554, 584
for school staff, 463, 585, 587–589 classification, 312–315
team approach, 391–392 Excipients, 144, 145, 208, 280, 456
Education programs, evaluation of, 589–597 Exercise
Educator, see Asthma educator induced asthma, 81, 82, 113, 114, 120, 157, 158, 180,
EIA, see Exercise, induced asthma 181, 196, 265, 276, 294, 431, 436, 454, 458,
Elderly, 57, 62, 65, 70, 181, 184, 195, 261, 309, 458, 497, 507, 615
612, 613 testing, 81–82
Electromagnetic, 438 as treatment, 437–438
Electronic, 71, 147, 162, 240, 390, 533, 536, 552, 554, as trigger, 157
573, 575 Exhaled breath condensate, 84, 163
642 Index
Expectorant, 281 Forced Expiratory Volume in 1 second (FEV1), see Lung

Expert Panel Report 3 (EPR 3), 20–21, 23, 63, volumes
212–214, 217 Forced oscillation, 57, 85, 86
Expiration, 41, 45, 48, 52, 60, 78, 102, 241, 302, 303, Forced Vital Capacity (FVC), see Lung capacities
311, 312, 343, 348 Formaldehyde, 156, 161, 163, 267, 586
Expiratory reserve volume (ERV), see Lung volumes Formoterol, 70, 113, 158, 183, 185, 186, 213, 236, 244,
Expiry date, 205, 227, 230, 236, 243–245, 526 276, 311, 317, 318, 356
Exposure reduction and avoidance, 133, 146–159 Fraction of exhaled nitric oxide, 77–78
Exposure to allergens, 9, 17, 117, 143, 383, 504 Frankl, 486
Frequently asked questions, 445–473
Functional Residual Capacity (FRC), see Lung capacities
F Fungi, 134, 148
Factors contributing to Fungus, 137, 307
allergies (see Allergy)
reproducibility, 69
seasonal changes, 115 G
severity, 112–115 Gag reflex, 230, 231, 263
Family Gardner, 495
adaptability, 384, 395, 544, 553 Gas exchange, 42, 52, 57
cohesion, 376, 384 Gas stoves, 140, 160
conflict, 381, 384 Gastroesophageal reflux, 22, 114, 115, 122, 123, 128,
dysfunctional, 376, 384, 518, 523 194, 195, 257, 263, 269, 270, 299–302
support, 380, 389, 396, 404, 406, 505, 520, 543 Gel bait, 151
Fasenra, 190 Genetic predisposition, 15, 17, 19, 260, 261
Fatal asthma, 364, 453; Genetics, 268
See also Potentially fatal asthma (PFA) and environment, 16–19
Fatigue, 6, 69, 113, 190, 277, 280, 294, 298, Genotype, 15, 16, 18, 113, 217
316, 354, 376, 381, 397, 438, 502, 506, Gerbils, 136
540, 558 GERD (gastroesophageal reflux disease)
Feather, 150 atypical symptoms, 300
Felder, 499 testing, 301
Felder-Silverman, 499 treatment, 301
FeNO, 77–78; Gestalt, 481–484
See also Nitric oxide - fraction of Gestures, 407, 411, 413
Fetal kick count, 259 Glaucoma, 181, 184, 186, 264, 296, 612, 613
Fetus, 161, 162, 187, 257–260, 271, 282, 465, 524, Global Initiative on Asthma (GINA), 8, 11, 19, 21,
617, 618 23–25, 29, 105, 191, 304
FEV1 (Forced Expiratory Volume (1 second), see Lung Glycoproteins, 46
volumes Goals of asthma management, 134
FEV6, 103, 212 Goals of treatment, 308, 398, 399
FEV1/FVC, 64–65 Goblet cells, 43, 44, 53
Finger clubbing, 99–100 Gold, 206
Flavorings, 154, 162, 208, 280, 456 Grass pollen
Flexhaler, 243–244 Bermuda, 134
Flovent, 355 Johnson, 134, 373
Flow volume, 66–67 Kentucky blue, 134
Flunisolide, 234 Orchard, 134
Fluticasone furoate, 238 ryegrass, 134
Fluticasone propionate, 184, 200, 204 timothy, 134
Food See also Pollen
additives, 142–143 Green zone, 315, 350
allergen, 153 Growth factors, 50
allergy, 141, 153, 261, 294, 300 Guidelines
anaphylaxis, 319 EPR3, 212–214
dyes, 143 GINA, 191
flavorings, 154, 162, 208, 280, 456 NHLBI, 20–23
intolerance, 141 Pediatric, 23–24
sulfites, 279 2020, 213
Forced Expiratory Flow25-75, 65 Guinea pig, 136
Forced Expiratory Flow Maximum, 65 Guthrie, 479–481
Index 643
H Hypertension, 79, 146, 182, 195, 257, 262, 264,

Hamsters, 136 269–271, 282, 296, 306, 457
Hay fever, 15–17, 40, 49, 115, 432, 462, 557, 614 Hypertrophied adenoids, 297
HDM, see House dust mites Hyperventilation, 52, 118–119, 144, 257, 302, 403, 428
Health beliefs, 373, 403, 407, 504, 505, 526, 529, 543 Hypnosis, 428, 429
Health care team, 26, 158, 391, 520, 527, 530, 560, 618 Hypoallergenic, 137, 463, 468
Health education, 12, 26, 406–407, 577 Hypotension, 143, 194, 205, 277, 278, 318, 321, 322
Health maintenance organizations, 26, 577 Hypoxemia, 47, 187, 266, 311, 527, 618
Health systems, 25–26, 596
Heart rate(s), 81, 82, 116, 180, 282, 312, 323, 427
table of, 314 I
Helium, 78 Iatrogenic, 320, 628
Henna, 293 Identification of triggers, 28, 133, 159, 353
Herbs, 297, 422, 426, 434–437, 473, 528 Idiopathic, 319, 320, 628
safety of, 435 IgE, see Immunoglobulin E
HFA IgG, see Immunoglobulin G
hydrofluoroalkane, 178, 225 Illiteracy, 12, 364, 382, 406
Priming, 229 Imagery, 426, 428, 483, 487
Hirsutism, 182, 382 Immunization, 156, 191, 265, 272, 432, 434, 470–471
Histamine, 49–51, 79–81, 83, 103, 141, 186, 190, 196, Immunoglobulin, 44, 49, 206, 628
277, 279, 320, 322, 622 Immunoglobulin A (IgA), 49, 628
Histamine challenge, 80–81 Immunoglobulin E (IgE), 15, 17, 22, 49, 103, 112, 115,
Histology, 43–44 138, 140, 141, 189, 190, 192, 197, 262, 271,
History, 8, 13, 17, 80, 81, 97–99, 108–112, 114, 115, 295, 307, 308, 319–321, 432, 628
123, 124, 128, 134, 143, 145, 177, 183, 187, blockers, 22, 190
193, 197, 207, 211, 212, 262, 267, 268, 274, Immunoglobulin G (IgG), 49, 192, 307, 308, 628
276, 277, 294, 295, 303, 304, 313, 319–321, Immunologic, 48–50, 103, 428
336, 354, 364, 404, 432, 448, 462, 465, 484, Immunomodulators, 22–24, 180, 183, 188–194, 203,
523, 525, 543, 574, 583, 612–614, 616, 620 271, 427
Holding chamber, 22, 178, 217, 225, 226, 228, 230–236, Immunosuppression, 307
247, 248, 250, 265, 387, 459–460, 509, 518 Immunotherapy
Holistic, 426, 434, 500, 524 subcutaneous, 197, 205, 206
Home monitoring, 62, 348–362 sublingual, 23, 197, 205, 206
Homeopathy, 297, 423–426, 432–433, 439 Impairment, 23, 63, 69, 100, 107, 109, 182, 212, 214,
Home visit, 161, 371, 375, 400, 582, 584, 585 215, 294, 295, 383, 457, 497, 502, 526
assessment, 582–584 Indoor allergen(s), 22, 23, 133, 135–139, 158, 382, 582
teaching kit, 584–585 Induced sputum, 84, 112, 193
Hormone, 124, 181, 182, 194, 207, 257, 427, 455, 458, Industrial smoke, 19
471, 492 Infection
Hospitalization, 10, 13, 28, 105, 133, 136, 163, 295, 305, control, 25, 86
310, 316, 350, 353, 360, 364, 376, 380, 382, viral, 18, 76, 110, 115, 120–122, 127, 139, 144, 156,
385, 387, 389, 435, 530, 540, 582 157, 159, 196, 312, 345, 450, 471, 556, 584
Host risk factors, 19 Information leaflets, 283, 572
House dust mites, see Dust mite Information processing theory, 478, 487–489, 499
Household chemicals, 140 Ingested allergens, 140–143
Hull, 479–481 Inhaled corticosteroids (ICS)
Humanistic theory, 484–486 effect on growth, 24, 458
Humidifier, 137, 148, 160, 452, 583, 586 problems, 115, 189, 191, 193, 195, 196, 270, 390
Humidity, 64, 81, 87, 134, 135, 137, 140, 148, 149, 156, side effects, 184, 185, 187, 188, 190–197
160, 225, 227, 235, 237, 241–244, 246, 400, Inhaled foreign bodies, 118, 119, 123, 312, 362
451, 452, 466, 582, 583, 586 Inhaler
Hydration, 293, 360, 394, 403, 542 cleaning, 227, 235, 237–239, 241–244, 246, 247, 249
Hydrofluoroalkane (HFA), 178, 225 replacement, 227, 228, 234, 238, 239, 241
Hydrogen peroxide, 140, 156 storage, 228–229, 236, 238, 239, 241, 243, 244, 248
Hydroxychloroquine, 206 technique, 105, 191, 194, 211, 214, 216, 231, 250,
Hygiene hypothesis, 18 265, 301, 387, 489, 491, 593, 595
Hygrometer, 160, 583 Inner city, 9, 10, 135, 136, 151, 316, 382, 385, 397, 504,
Hyperinflation, 101, 304, 312 575
Hyperlipidemia, 270 Insect allergen, 154–155
Hyperplasia, 53 Insecticide, 151, 154
644 Index
Inspiration, 40, 41, 44, 48, 52, 58–60, 64, 67, 70, 71, 85, children, 495–496
102, 119, 225, 229, 231, 235, 236, 246, 247, the elderly, 497
302, 311, 312, 314, 361 implications, 497–500
Inspiratory capacity, see Lung capacities theories, 476–510
Inspiratory flow rates, 235, 236, 250, 530 types of learning, 497, 501
Inspiratory reserve volume (IRV), see Lung volumes Lesions, 103, 293
Inspiratory volume, 66, 265 Leukotriene modifiers
Inspired cold air, 82–83 leukotrienes, 184, 186, 187
Intal, 196, 202, 456 receptor antagonists or inhibitors, 186–188, 201, 213,
Integrative medicine, 426 265, 629
Intercostal, 44, 45, 48, 101, 310, 312, 628 Leukotriene receptor antagonist (LTRA), 186–188, 191,
Interleukin, 49, 189, 190, 628 194, 196, 201, 213, 265, 629
Intermittent, 22–24, 106, 107, 109–111, 125, 192, 209, Levalbuterol, 198, 204, 229
212, 213, 258, 295, 302, 311, 377, 481 Lewin, K., 482
Internet sites, 576 Lichenification, 103, 293, 627
Interrupter, 57, 80, 84–86, 534 Lifestyle, 10, 18, 28, 110, 133, 157, 159, 189, 213, 249,
Intolerance, see Food 270, 271, 338, 370, 373, 378, 381, 385, 386,
Intubated, 25, 212, 364 388, 393, 396, 399, 401–403, 406, 407, 424,
Investigation, 53, 97, 103–104, 112, 113, 116, 122, 299, 430, 434, 437, 453, 501, 506, 515, 520–522,
305, 390, 430, 550, 585, 620 524, 538, 557, 603
Iodides, 259 Life-threatening exacerbation, 25, 99, 128, 315
Ipratropium bromide, 158, 201, 296, 317 Literacy, 15, 28, 283, 341, 364, 373, 388, 407, 410, 502,
Irritants, 17, 48, 49, 51, 82, 98, 114, 116, 124, 133, 503, 506, 515, 524–527, 529, 543, 546, 553,
139–140, 143–146, 155–156, 159–161, 186, 554, 576–578, 583–585, 589, 595
191, 205, 214, 263, 266, 292, 294, 303, 360, Lobe, 41, 42, 103, 112, 629
446, 449, 451, 467, 504, 582, 585, 588 Long-acting beta agonist/bronchodilators (LABA), 22,
Isocyanates, 116, 267 70, 115, 179, 185–187, 189, 191, 194, 199,
Isoproterenol, 279 204, 207, 209, 211, 213, 236, 258, 311, 340,
355, 453, 455, 456
Long-acting muscarinic agent (LAMA), 23, 185–186,
K 191, 201, 204, 213, 628
Kallikrein, 51 Low literacy, 506, 515, 525–526, 529, 574, 577,
Knowles, M., 496, 497 578, 585
Kolb, D., 498, 499 Low socio-economic, 10, 11, 136, 364, 373, 382, 383,
575, 577, 578;
See also Poverty
L LTRA, see Leukotriene receptor antagonist
LABA, see Long-acting beta agonist/bronchodilators Lung cancer, 99, 118, 161, 471
Lactose Lung capacities
- in medications, 154, 208 forced vital capacity, 59–61
- intolerance, 141 functional residual capacity, 59, 60, 65
Ladybugs, 133, 137–138, 155 inspiratory capacity, 59, 60
LAMA, see Long-acting muscarinic agent total lung capacity, 59, 60
Laryngoscopy, 302, 303 vital capacity, 59, 60
Laryngospasm, 118 Lungs
Larynx, 41, 45, 48, 303, 629 cellular defenses, 49
Late reaction, see Biphasic dead space, 52, 57, 62, 65, 85, 247
Latex, 133, 138, 139, 142, 158, 267, 292, 319 lobes, 41, 42, 103, 112, 629
Learning Lung volumes
age-related, 491, 493, 495–501 expiratory reserve volume, 58, 59
barriers, 501–506 forced expiratory volume in one second (FEV1),
computer-assisted, 489–490 59–61
definition, 477 inspiratory reserve volume, 58–60
fostered by, 492, 510 residual volume, 58, 59
online collaborative, 489–491 tidal volume, 58–60
principles, 476–510 Lymph, 100, 101
process, 476–478
strategies, 488, 496, 497, 501, 507, 510
styles M
adolescents, 496 Macrophage, 7, 49, 629
adults, 496–497 Malaise, 277
Index 645
Management guidelines, see Guidelines Minimum inspiratory flow rates, 236, 250
Management of asthma, 7, 23, 27, 57, 133, 146, 260, Mobile app, 240, 530–532
263, 302, 336, 351, 383, 384, 391, 392, 536, Mobile phone, 273, 275, 573
560, 617 Mold
anaphylaxis, 261, 318–324 indoor, 137, 148
Management problems by age, 336, 345–348 outdoor, 134, 148
Management skills, 403, 600 Mometasone, 186, 200, 203, 204, 229, 241, 296
Mannitol, 280, 320 Monitoring by
Marijuana, see Cannabis patient, 361
Mask, 24, 25, 85, 138, 147, 148, 150, 157, 232–235, asthma apps, 63, 126–127, 531
245–247, 249, 409, 471, 585, 618, 619 Monoamine oxidase (MAO) inhibitor, 282
Maslow, A., 485, 486, 491 Monoclonal, 22, 23, 188–191, 217, 283, 284
Massage, 297, 318, 361, 424, 426, 433, 434 Monosodium glutamate (MSG), 141, 143, 322
Massage therapy, 360, 361, 423, 424, 426, Montelukast, 187, 188, 196, 201, 204, 213, 296
433–434 Morbidity, 9–11, 30, 136, 137, 158, 162, 259, 266, 269,
Mast cells, 7, 46, 49, 50, 83, 181, 190, 195, 277, 296, 271, 310, 346, 350, 362, 376, 380–383, 398,
321, 629 407, 525, 581, 582, 596, 629
Mastocytosis, 321, 322 Mortality, 11–12, 184, 186, 257, 259, 264–266, 269, 305,
Maxair, 199 313, 316, 346, 350, 364, 382, 389, 407, 465,
MDI 525, 569, 592, 596, 629
common errors, 229–230 Mouse, 136, 153, 188, 383, 586
disadvantages, 225, 230 Mouth breathing, 294
replacement, 228 Mouthpiece, 25, 63, 69, 71, 74, 85–87, 226, 227, 229,
storage, 228–229 231, 232, 234–247, 249, 339, 353, 459, 460,
technique, 226–227 570, 584
Mechanism Mucins, 44
defense, 40, 43, 48–50, 112 Mucolytics, 197, 259, 629
immunologic, 48–50 Mucosa, 40, 41, 43, 49–51, 87, 100, 120, 141, 142, 257,
Medical history, see History 629
Medication sensitivity, 144–146 Mucus, 41, 43–46, 48, 49, 51–53, 103, 112, 181, 185,
Medications - non asthma, 277–283 186, 191, 307, 314, 337, 436, 446, 448, 537,
over the counter (OTC), 281–283 558, 573
Medications to treat Mucus plugs, 51–52, 78, 103, 112, 266, 307
asthma Mugwort, 134, 142
onset of effectiveness, 204 Murray, H., 485, 491
side effects, 204 Muscarinic, 179, 185, 271
GERD, 301 Myelin, 45
rhinitis, 296 Myocardial infarction, 278, 322
Medication use, principles of, 178–179 Myopathy, 182, 629
Meditation, 426, 427
Medulla, 48
Memory, 10, 138, 262, 264, 280, 306, 342, 348, 383, N
487, 489, 497, 500–502, 506, 527, 539, 551, NAEPP, see National Asthma Education and Prevention
553, 592–594 Program
Menses, 98, 159 Nasal congestion, 138, 277, 294, 296, 298, 538
Menstrual, 159, 269, 275, 471 Nasal lavage, 297, 298
Mepolizumab, 113, 189, 190, 203 Nasal polyps, 113, 128, 144, 277, 297–299, 347
Metabisulfite, 143, 208, 263, 278, 319 Nasal septum, 40, 297
Metabolic, 141, 269 Nasal sprays, 274, 296
Methacholine, 79–83, 103, 128, 303, 428, 431 National Asthma Education and Prevention Program
Methacholine challenge, 79, 81, 83, 303, 431 (NAEPP), 21, 63, 75, 77, 107, 146, 203, 349,
Methotrexate, 206 352, 407, 592, 604
Methylprednisolone, 201, 204, 317 Naturopathy, 423, 434
mHealth, 530 Nebules, 179
Mice, 136, 153, 160, 267 Nebulizer
Micrognathia, 100 advantages, 246–247
Mildew, 137 disadvantages, 246–247
Milk allergy, 140, 436 substitute device, 247
Mind-body therapies, 426 ultrasonic, 247
646 Index
Nedocromil, see Tilade Orange zone, 350

Nerves Oropharyngeal, 185, 190, 191, 225, 230, 231
autonomic, 45, 48, 51, 426, 427 OSA, see Obstructive sleep apnea
cranial, 45 Osteomalacia, 182
intercostal, 45 Osteopathy, 429, 430
laryngeal, 41, 45 Osteoporosis, 182, 264, 458
phrenic, 41, 44, 45, 630 Ostiomeatal complex, 41
vagus, 45, 48, 631 OTC medications, see Over-the-counter medications
Nervous system of the lungs, 45–46 Otolaryngologist, 119, 127, 297, 299, 303
Neuropeptides, 426 Outcome(s)
Neurotransmitter, 45, 185, 426 health care utilization, 310, 387
NHLBI guidelines, 18, 20–23, 107, 183, 191, 349, 381, patient management, 574
386, 387, 392, 574 Outdoor allergens, 133–135
Nicotine, 162, 163, 273–275, 309, 346, 347 Over-the-counter (OTC) medications, 144, 145, 154,
Nicotine replacement, 273–276 197, 259, 264, 273–275, 278, 281–283, 456,
Nitric oxide - fraction of (FeNO), 77–78, 127, 163, 502, 526
192, 260 Overweight, 162, 269, 270, 306, 309
Nitrogen dioxide, 140, 160, 312 Oxygen saturation, 81, 84, 86, 116, 312, 314, 315, 461
Non-adherence Ozone, 139, 264, 312
identifying, 390–391, 544
patterns of, 389–390
Non-adrenergic, 44, 45 P
Non-pharmacologic, 157, 191, 297 Pacing, 488, 509, 553
Non-steroid anti-inflammatory drug (NSAID), 145, Palpation, 101, 271
147, 259, 263, 264, 277, 278, 281, 282, 295, Panic, 47, 118, 119, 126, 144, 309, 322, 362, 363, 376,
300, 320 379, 381, 397, 403, 472
Norepinephrine, 45, 46, 629 Parasympathetic, 45, 46, 48, 185, 629
Normal values, see Values Parenchyma, 42, 48
NSAID, see Non-steroid anti-inflammatory drug Parenteral, 138, 321
Nucala, 189, 190, 203 Paresthesia, 125
Nutrition, 19, 69, 261, 309, 383, 397, 430, 434, 436–437 Participation, 109, 412, 469, 510, 518, 520, 534, 536,
Nutritional supplements, 276, 436–437 544, 548, 549, 553, 588, 613
Particulate matter, 147
Pathophysiology, 30, 50–54, 77, 393
O Patient assistance programs, 399
Obesity, 19, 22, 77, 102, 157, 191, 195, 262, 263, Patient centered care (PCC), 407
268–272, 292, 300, 338, 457, 523 Patient education
Objective measures, 7, 11, 104, 106, 178, 215, 312, 314, issues, 27–28
353, 427, 428, 430, 431, 588 principles of, 30, 177, 549–550
Obstructive sleep apnea (OSA), 8, 22, 268, 269, 271, Patient records, 574
294, 297, 305–306, 347, 629 Patterns of asthma, 109–116, 477
Occupation, 60, 62, 63, 116, 124, 140, 249, 266, 267, Pavlov, I., 478, 479, 481
338, 375, 383, 393, 396, 527, 618, 619 Peak expiratory flow (PEF)
Occupational asthma, 77, 115–116, 128, 138, 140, benefits of using, 360
141, 246, 266–268, 295, 348, 377, 396, 405, calculating diurnal variability, 75, 351–352
406, 619 calculating reversibility, 74
Occupational sensitizers, 19 charts, 74–76, 349
OCS, see Oral corticosteroids classification of severity using, 348, 350, 351, 353,
Odors, 100, 119, 133, 140, 155, 156, 160, 263, 298, 303, 360
305, 502 diary, 75, 349, 353–355
Olympic, 82, 158, 276, 277, 454, 516 diurnal variation, 75, 351, 354
Omalizumab, 22, 113, 189–191, 203, 207, 258, 259, manipulation of peak flow meter, 74
299, 308 measurement, 76, 348, 353
Online collaborative learning (OCL), 490, 491 meter, 348–355
Oral allergy syndrome, 142, 319, 629 normal values (see Values)
Oral corticosteroids (OCS), 24, 25, 76, 99, 105, 108, 128, patient use in monitoring, 348–350, 353–355
162, 182–184, 187, 191–194, 201, 206, 207, personal best, 349–352
211–214, 258, 260, 263, 264, 271, 295, 296, personal best reading, 350–352, 354
299, 301–303, 308, 312, 314–318, 321, 350, recommended for, 75–77, 351, 352, 354
357, 376, 456, 457, 521, 532 sequence of steps
Index 647
in teaching, 71, 357, 360, 362 Plethysmography, 57, 60, 78–79, 81, 85
for using, 71 Pneumothorax, 102, 312, 314
serial measurement, 348 Pollen
table of reference values -allergy (see Oral allergy syndrome)
adults, 60, 351, 352, 360 -food cross reactivity, 142
children, 351, 352, 354, 360 season, 134, 142, 147, 148, 157, 279
technique, 349, 352–353 Pollution
use in an exacerbation, 348, 351, 353–355, 360 indoor, 19
use of, 350, 352 outdoor, 19, 139
variability, 349, 351–352, 355 Polypharmacy, 396
who should use, 352, 354 Polysomnography (PSG), 297, 306
zones, 350, 356, 358, 359 Post-ganglionic neuron, 45
Peak flow, see Peak expiratory flow (PEF) Postnasal drip, 123, 298, 304
Pediatric guidelines, 23–24 Potentially fatal asthma (PFA), 309, 363–364
Penicillium, 134, 135, 148 Poverty, 9, 10, 24, 160, 309, 316, 381–383, 385, 485,
Peptides, 44 516, 518;
Perception, 7, 28, 105, 106, 138, 179, 185, 208, 209, 265, See also Low socio-economic
281, 316, 353, 354, 360, 378–380, 391, 393, Precision health, 188–193, 425
397, 423, 479, 482–484, 493, 499, 506, 524, Predicted values, see Values
526, 538, 540–542, 547–549, 552, 554 Prednisolone, 201, 204, 258, 317
Percussion, 101–102 Prednisone, 76, 183, 194, 201, 204, 258, 301, 303,
Perfume, 140, 155, 263, 292, 344, 375, 377, 395, 396, 317, 350, 363, 391, 439, 457, 464, 471, 619,
439, 550 622, 623
Perinatal, 257, 465 Pregnancy
Permeability, 150, 321 anaphylaxis in, 259, 261
Personality development, 491–495, 503 asthma in, 256–261
Personal responsibility, 27, 492 immunization, 265, 470–471
Pertussis, 18 immunotherapy, 259
Pets, 18, 19, 99, 114–116, 121, 122, 133, 136–137, monitoring, 260
139, 144, 151–152, 160, 163, 294, 295, 316, Premenstrual symptoms, 159
338, 348, 371, 375, 390, 395, 396, 400, 439, Prescription, 13, 22, 28, 105, 122, 132, 144, 146, 147,
462, 466–468, 519, 522, 537, 551, 585, 602, 187, 188, 197, 198, 208, 248, 264, 274, 278,
620, 623 281–284, 297, 300, 338, 340, 364, 373, 374,
pH, 47, 103, 163, 208, 257, 301, 314, 630 381, 385, 386, 388–391, 399, 400, 422, 424,
Phagocytic, 49 456, 459, 466, 574, 578, 594, 612, 613, 617,
Pharmacogenetics, 17 621, 622
Pharyngitis, 138, 190, 298 Preservatives, 84, 98, 141, 143, 144, 147, 179, 208, 263,
Phenotype, 15–17, 22, 77, 83, 84, 104, 112–113, 188, 278, 280, 319, 320, 456
192, 193, 217, 262, 268, 630 Primary muscles, 44
Phrenic nerve, 41, 44, 45, 630 Priming
Physical education, 24, 99, 377, 395, 405, 464, 518, 519, initial, 227, 228
522, 587, 588 non-use, 229, 230
Physical examination, 6, 97, 99–103, 121, 141, 277, 295, Principles of communication, 549–550
298, 409, 574 Principles of medication use, 178–179
Physiological, 48, 57, 84, 262, 263, 276, 348, 403, 404, ProAir, 198, 229, 239
427, 428, 485, 523, 526, 545, 592 Problems by age
Piaget, J., 483, 484, 493–495, 518 diagnosis, 345, 346, 348
Pigweed, 134 management, 345–348
Pine nuts, 319 Process of
Pinon, 319 education, 493, 536–542, 552, 594
Pirbuterol, 199, 204, 317 learning, 404, 476–478, 480, 482, 484, 485, 493,
Pituitary, 147, 181, 182, 266 499–501, 508, 542, 547, 556, 598
Placebo devices, 250, 571, 579 teaching, 4, 32, 406, 428, 476, 477, 489, 504, 507,
Planning for teaching 538, 542, 546, 547, 553, 555, 558, 562, 580
assessment, 542–544 Prostaglandin, 184, 277, 282, 320
evaluation, 546–548 Protocol for teaching
implementation, 546 peak flow meter, 339, 342
sample teaching plans, 548–549 peak flow zones, 340, 343
Plateau, 67, 81, 509 Proton pump inhibitor, 301
Platelet activating factor, 51, 277, 629 Proventil, 198, 229, 355, 356, 408, 501
648 Index
Pruritis, 321, 630 Receptors, 46–49, 181, 185, 190, 193, 487, 630
Pseudoephedrine, 259, 281, 282, 296 Reduced activity, 6, 136, 526
Psychiatric, 10, 187, 188, 194, 302, 310, 362, 364, 380, Red zone, 350, 572
385, 457, 518, 523 Reference values, see Values
Psychological, 10, 141, 157, 192, 208, 263, 269, 294, Referral to a specialist, 127–128, 405
303, 306, 310, 312, 363, 376–379, 381–384, Reflexology, 297, 424, 426, 434, 438
389, 392, 397, 403, 406, 407, 426, 484, 488, Refusal to change, 389, 390
491, 492, 497, 501, 505, 518, 523, 527, 546, Reinforcement, 30, 342, 344, 392, 401, 403, 479–481,
551, 560 489, 493, 494, 507, 509, 541, 542, 546–548,
Psychomotor, 537, 541–542, 544–546, 548, 549 556–558, 561, 580, 599, 601
Psychomotor domain Relaxation
planning for, 545–546, see Domains exercises, 380, 393, 403, 472, 481, 542, 547, 562
Psychosocial, 10, 15, 30, 191, 194, 208, 270, 312, 363, techniques, 303, 360, 361, 397, 403, 423, 427, 429,
364, 380, 382, 385, 400, 491, 518, 519, 523, 481, 524
524, 548, 581 as therapy, 422, 427, 433
Psychosocial factors, 10, 108, 117, 212, 381–385, 400, Reliever, 25, 75, 105, 117, 144, 180, 191, 204, 213, 215,
505, 523, 544 228, 266, 300, 304, 311, 340, 356, 390, 394,
Psychosomatic, 141, 447 395, 447, 453–456, 461, 464, 519, 521, 544,
Pulmonary, 17, 23, 40, 42, 43, 48, 49, 52, 59, 60, 62–65, 548, 555, 587, 595, 596, 615
70, 75, 79, 80, 84, 103, 104, 106, 114, 116, Religion, 403, 408, 413, 429, 505, 539, 543, 600, 601
120, 135, 155, 157, 159, 163, 185, 194, 212, Religious differences, 30, 407–414
215, 257, 264, 272, 294, 300, 302, 304, Remission, 5, 8, 121, 261, 308, 372, 402, 449, 616, 623
306–309, 312, 439, 630 Remodeling, 53, 54, 125, 311, 337
Pulmonary embolism, 123, 262 Reproducibility, 69, 352
Pulmonary function test factors affecting, 69
interpretation, 71, 73 Residual volume (RV), see Lung volumes
sample test, 73, 85 Resistance, 48, 57, 60, 62, 78, 79, 81, 85, 86, 180,
Pulmonologist, 127 232, 268, 271, 293, 298, 375, 411, 412, 437,
Pulse oximetry, 60, 84, 314, 317 505, 555
Pulsus paradoxus, 6, 102, 116, 310, 312, 314–316 Reslizumab, 189, 191
Pyrethroids, 137, 155 RespiClick, 236, 239, 240
Respiration, 41, 42, 45, 47, 48, 52, 57, 78, 81, 101, 116,
195, 233, 310, 312, 437
Q Respiratory changes in asthma, 312
QOL, see Quality of life Respiratory illness, 19, 259
Quality control Respiratory rate, 81, 86, 99, 116, 310, 312, 314, 315,
CAM, 425 427, 461
spirometry, 86, 87 Respiratory tract, 40–45, 49, 52, 109, 120, 140, 161, 163,
Quality of life (QOL), 5, 6, 8–11, 14, 15, 22, 23, 28, 178, 205, 277, 279, 302, 321, 322, 630
30, 120, 125, 126, 132, 139, 161, 179, 190, Response to
191, 205, 207, 212, 215, 216, 225, 250, allergen, 120
263–265, 269–271, 294, 295, 305, 309, 337, exercise, 120
364, 373, 378, 382, 388, 389, 401, 406, viral infection, 120–121
427–429, 433, 521, 524, 530, 531, 534, 548, Restaurant syndrome, 322
549, 569, 591, 594 Reversibility, see Peak flow
scores, 14, 15, 215–217, 572, 594 Rhinitis
Quick relief, 22, 179–183, 185, 205 allergic rhinitis, 17, 40, 41, 49, 50, 81, 114, 115, 142,
Qvar, 199, 229, 408 158, 190, 261, 262, 293–299, 307, 347
perennial rhinitis, 294, 295
Rhinorrhea, 277, 278, 294, 296–298, 321
R Rhinosinusitis, 128, 191, 293–299, 306, 424
Radio-contrast, 320, 322 Rib cage, 6, 44–45
Ragweed, 49, 134, 142, 147 Risk
Random use, 389, 390 domain, 107–109, 214
Rapid eye movement (REM), 47, 630 factors, 10, 16, 18, 19, 21, 108, 109, 135–137, 160,
Rare syndromes, 322 162, 191, 212, 266, 269, 271, 295, 304–306,
Rats, 136, 160, 267 309, 316, 320, 321, 363, 364, 384, 385, 465,
Reassurance, 187, 209, 259, 304, 338, 399, 523, 574, 586
517, 533, 549, 552, 558, 570, 580, Rodents, 133, 136, 153
597, 598 Rogers, C., 484, 485
Index 649
Role of educator, 7, 9, 337 Silverman, 499

Role playing, 398, 405, 532, 620 Singulair, 201, 296
Sinus, 100, 103, 297–299, 306, 462
Sinusitis
S diagnosis, 298
SABA, see Short-acting beta agonist/bronchodilators medical management, 298
Saccharin, 208, 280 predisposing factors, 297
Salmeterol, 70, 158, 185, 186, 199, 202–204, 229, 237, symptoms, 298
276, 355, 386, 622 Skills
School attack management, 403
inner-city, 136 educator (see Asthma educator)
medical, 423 prevention, 404
School environment self-management, 401–406
policies, 585, 587–588 social, 404–406
staff, 585, 588–589 Skin disease, 103, 293
Scoliosis, 101 Skinner, 479–481
Secondary gain, 505 Skin test, 15, 103, 136, 141, 192, 197, 262, 299,
Selecting 307, 432
an inhaler, 249 Sleep, 6, 7, 9–11, 47, 82, 96, 106, 114, 126, 133, 149,
a device, 249 152, 187, 188, 196, 269, 281, 294, 295, 297,
Self-efficacy, 392, 401, 508, 520, 524, 558, 561, 598 305, 306, 339, 354, 360, 380, 383, 399, 447,
Self-evaluation, 402, 404, 480, 485, 529, 533, 536, 590, 448, 450, 554, 593, 620
597–599, 602 Sleep apnea, 114, 305–306
checklists, 598–602 SLIT, see Sublingual immunotherapy
Self-management, 12, 27–29, 31, 126, 132, 176, 250, Slow-mist inhaler, 227
257, 304, 318, 341, 345, 348, 354, 359, 360, Smoke
371–372, 380, 390, 401–406, 508, 520, 531, industrial, 19
532, 545–548, 551, 558, 560, 561, 569, 572, tobacco, 19, 65, 98, 116, 119, 139, 155, 161, 162,
580, 581, 592, 593, 599, 600 294, 295, 303, 320, 347, 452, 453, 471, 503,
Self-monitoring, 343, 380, 401–403, 406, 561, 599 504, 585, 586
Sensitivity, 30, 32, 78, 113, 141–147, 257, 264, 269, wood, 19, 133, 140
277–279, 282, 299, 319, 414, 529, 530, 577 Smoking cessation, 139, 161, 162, 191, 273–275, 304,
Severe acute asthma, 6, 52, 101, 102, 116–117, 179, 180, 310
183, 245, 258, 314 Smooth muscle, 43–46, 48, 51–53, 70, 118, 120, 180,
Severe asthma, 9–12, 24, 25, 52, 77, 83, 96, 98, 184, 185, 195, 206, 279, 311
104–109, 112, 113, 128, 155, 183, 190–194, Snoring, 294, 306, 347
196, 205, 206, 208, 209, 211, 231, 258–260, Social determinants, 9, 10, 136, 162, 205, 373, 382,
266, 269, 277, 300, 301, 312, 313, 317, 318, 385, 491
347, 350, 354, 362–363, 383, 384, 425, 429, Social support, 373, 379, 383, 398, 505
449, 450, 458, 463–465, 470, 519, 528, 554, Social worker, 25, 26, 467, 470, 523, 551,
571, 592, 596 557, 560
Severity Socioeconomic, 9–11, 17, 30, 62, 69, 136, 139, 152, 159,
of an exacerbation, 15, 22, 24, 25, 105, 107, 116, 162, 212, 268, 271, 292, 309, 364, 373, 382,
127, 139, 141, 180, 183, 257, 259, 266, 277, 383, 406, 490, 491, 500, 502, 504, 575, 577,
306, 314, 364, 530 578, 601
assessing severity, 7, 8, 105, 106, 177, 351 Sodium benzoate, 280
classification after treatment, 209–211 Somatic, 45, 48, 208, 630
classification before treatment, 107–108, 209 Sorbitol, 208, 280
factors contributing to, 112–115 Spacer, 22, 25, 178, 185, 199, 208, 217, 225, 226,
Severity, levels of 230–235, 247–250, 265, 317, 346,
intermittent, 109 459–460, 509, 518, 527, 531, 585,
mild persistent, 109 614–617, 621
moderate persistent, 108, 109 requirements, 232–235
severe persistent, 109 Sphincter, 195, 300, 301
Sex and gender differences, 124 Spinal cord, 45, 47, 48
Shared decision making, 371, 524, 527, 544 Spiriva Respimat, 201, 227, 231
Short-acting beta agonist/bronchodilators (SABA), 22, Spirogram
23, 74, 107–109, 179–181, 184, 185, 191, 205, interpretation, 65, 70
211– 215, 260, 305, 311, 314–318, 355, 364, unacceptable, 66, 67
371, 453, 531 Spirometer, 59–65, 71, 78, 86, 87
650 Index
Spirometry Systems
body position, 69–70 health, 25–26, 203, 581, 582, 596
criteria for acceptability, 68–70 respiratory, 40, 86, 257, 312, 526, 529, 589
for diagnosis, 63, 64
for evaluations, 63
factors affecting reproducibility, 69 T
for monitoring, 62–64 Tachycardia, 46, 118, 180, 181, 195, 207, 208, 280, 317,
patient factors, 69 321, 322
premature termination, 66 Tachypnea, 119, 303, 631
quality control, 86 Tail off, 230
technical requirements, 68 Tannic acid, 149, 152
technologist, 61, 63, 64, 68–70 Tartrazine, 143, 208, 320, 631
use of bronchodilators in, 68, 70–71 Tattoo, 293
use of nose-clip, 64 Teach back, 340, 526
uses, 61–63 Teaching
wait times for bronchodilators before, 70 adolescents, 517, 520–523
Sputum, 5, 25, 50, 84, 98, 103, 112, 118, 192, 193, 197, adults, 523–525
265, 267, 307, 592 aids, 526, 527, 532, 533
Status asthmaticus, 116–117, 310, 360 approaches, 515–532, 536, 560–562
Stenosis, 122 children, 518–520
Step-up approach to treatment, 107, 214 climate, 550–552
Steroids definition, 520, 522, 529, 533, 545
and growth, 194 devices, 527, 530, 533, 541, 544, 548, 555, 560
inhaled, 12, 28, 76, 104, 111, 178, 226, 249, 258, elderly, 526–528
355, 389, 455, 505, 592, 593, 621, 622 environment, 520, 521, 523, 528, 534, 539, 543, 544,
oral, 24, 76, 77, 109, 201, 204, 345, 470, 592 547, 549, 550, 552
side effects, 179, 182–183, 204, 521, 592 evaluation, 537, 538, 546–548
Stigma, 283, 376–378, 383, 405, 505, 527 goals of, 524, 527, 542–544, 546–548, 552–554, 557,
Stimulus, 52, 182, 184, 478–484, 487, 489, 493 560, 561
Storage of devices, 228–229, 238, 239, 241, 243, 244, 248 in the home, 516, 523, 524, 530, 544
Stress, 5, 8, 10, 15, 22, 116, 119, 139, 144, 146, 163, individual, 533–534
182, 184, 208, 212, 266, 269, 273, 303, 312, kit, 515, 518, 519, 522, 532, 543, 546, 548, 549, 556,
322, 340, 363, 374, 376, 377, 379–384, 391, 557, 562
393, 397, 398, 401, 406, 407, 412, 414, large group, 532, 535–536
426–429, 432, 435, 437, 447, 450, 467, low literacy, 525–526
469, 470, 502, 503, 509, 540, 547, 555, 561, methods, 532–536
598, 614 older adults, 515, 526–528
Stridor, 119, 122, 302, 303, 321, 631 parents, 515–518
Subcutaneous immunotherapy (SCIT), 197, 205, 206 primary, 393, 540, 553, 561
Subepithelial, 53 problems caused by, 552–554
Sublingual immunotherapy (SLIT), 23, 197, 205, 206 process, 536–542
Subluxation, 430 in the school, 516, 518, 519, 522, 523, 527, 534, 547,
Submucosa, 43, 53, 299 557, 560
Sudden infant death syndrome (SIDS), 162 secondary, 393
Suicide, 187, 309, 310 skills, 516, 517, 519, 523, 525, 527, 529, 530,
Sulfites, 142, 143, 208, 278, 279, 319, 322 532–534, 536, 537, 540–547, 549, 553–556,
Sulfite sensitivity, 143, 278–279 558, 559
Sulfur dioxide, 51, 139, 143, 160, 161, 278 small group, 532–535
Sunset Yellow #6, 143 strategies, 554–559
Support, see Family, support team approach to, 560–562
Swollen eyelids, 322 tertiary, 394
Symbicort, 186, 203, 229, 356 See also Anticipatory guidance; Teaching, approaches
Sympathetic, 44–46, 207, 521, 543, 559, 601, 631 Teaching materials, 502, 560, 562, 570, 579, 595
Symptom diary, 111, 301, 346, 533, 571–572 evaluation, 570, 577–578
Symptoms Team approach, 336, 358, 391–392, 534, 551, 559–562,
premenstrual, 159 599
See also Asthma, symptoms Technology, 190, 240, 271, 374, 388, 489, 522, 523, 530,
Syndrome, 103, 135, 139, 142, 262, 265, 302, 319, 531, 573–575
322, 521 Telemedicine, 531, 574–575
Index 651
Terbutaline, 70, 158, 180, 199, 204, 242, 243, 258, 277, U
317, 631 Ultrasonic distilled water, 83
Testing, see Bronchial challenge; Peak flow; Pulmonary Ultrasonic nebulizer, 247
function; Spirometry Ultrasonic sound, 151
Testing adults, 87 Umeclidinium, 185, 203
Testing infants, 84–85 Uncontrolled asthma, 9, 10, 12–14, 75, 105, 186,
Testing preschool children, 85–86 194, 215, 216, 259, 260, 304, 465, 531,
Tezepelumab, 193 560, 613
Theophylline, 158, 179, 188, 195–196, 202, 204, Under-assessment, 11
213, 259, 260, 264, 282, 301, 346, 362, 386, Under-treatment, 11, 256, 257
456, 622 Urticaria, 137, 138, 141, 143, 205, 208, 277, 278, 321,
Theories of learning, 476, 478–489, 493–495, 510 322, 631
application, 493–495, 510
Therapeutic, 29, 54, 63, 104, 185, 189, 195, 203, 256,
259, 281, 282, 433, 555, 578, 584 V
Therapeutic touch, 426, 428–429 Vaccination, 197, 259, 265, 272, 304, 430
Thorndike, 479, 481 Values
Thrush, 185, 204, 226, 250, 265, 455, 458, 460, 509, 631 normal, predicted, reference, 60–62, 64, 65, 70, 71,
Thunderstorm, 134 85, 106, 258, 262, 349, 350, 391
Tidal volume (TV), see Lung volumes tables (peak flow), 355, 400
Tilade, 196, 455, 456 Valved holding chamber, 230–235, 518
Time course of events Vaping, 133, 162–163, 275, 276, 347, 587
response to allergens, 120 Variation
response to exercise, 120 diurnal, 75, 80, 114, 120, 194, 271, 349–352, 354,
response to viral infection, 120–121 360, 362, 461, 627
Tiotropium, 185, 186, 191, 201, 204, 227, 229 in heart rates, 81, 82
Tobacco, see Smoke Vascular rings, 121, 122, 631
Tolman, E., 482, 483 Vasodilation/vasodilatation, 185, 321, 631
Total Lung Capacity (TLC), see Lung capacities Vasomotor rhinitis, 297
Toxin, 18, 141, 262 Vasovagal, 322, 631
Trachea, 41, 44, 48, 52, 57, 65, 100–102, 122, 300, Venom, 319, 320
555, 631 Ventilation
Tracheobronchial tree, 41–43 of the lung, 52
Traffic signal, 507, 521, 571 main regulators of, 47
Transgenerational, 162 primary muscles of, 44
Travel, 48, 53, 117, 375, 453, 465–466, 516 of structures, 47, 52
Treatment Ventolin, 198, 225, 229
at home, 316–317 Videoconferencing, 490, 491, 575
in the office, 317–318 Vilanterol, 203, 238
Treatment, acute, 116, 292, 295–297, 299, 301 Viral infection, 18, 76, 110, 115, 120–122, 127, 139,
Treatment, add-on options, 185, 186, 188, 190, 191, 144, 156, 157, 159, 196, 312, 345, 450, 471,
206, 211 556, 584
Tree pollen, 134 Virtual, 5, 26, 414, 490, 491, 574, 575, 578
Trelegy Ellipta, 203, 239 Virus
Tremor, 46, 158, 180, 181, 198, 204, 264, 282, 296, 323 Covid, 5, 24–26, 97, 140, 156, 206, 270, 272, 373,
Trendelenburg, 322 375, 409, 470, 490, 491, 574, 575
Triad asthma, 277 RSV, 121, 144, 630
Trial of therapy, 104 Visual aids, 533, 535, 536, 562, 573, 584
Triamcinolone, 184, 201, 296 Vital Capacity (VC), see Lung capacities
Trigger Vitamin C, 437
allergic, 6, 205 Vocal cord dysfunction (VCD), 81, 119, 123, 144,
non-allergenic, 19, 143–146 302–304, 320, 322, 362, 381
See also Allergens; Irritants Vocal cords, 41, 45, 48, 66, 83, 119, 300, 302, 303
Tri-sodium phosphate (TSP), 156 Volatile organic compounds (VOC), 140, 156, 586
Troleandomycin, 206 Volumes, see Flow volume
Turbinate, 40, 41, 631 Volume time curves, 67–68
Turbuhaler, 178, 236, 242–243, 458–460 Vomiting, 6, 122, 141, 163, 195, 201, 204, 205, 208, 278,
Turbulence, 40–42, 134 300, 321, 323, 448, 517
Twisthaler, 200, 236, 241–242 Vygotsky, L., 488, 493, 494, 503
652 Index
W X
Warning signs, 6, 310, 311, 346, 354, 360, 403, 404, 453, Xolair, 189, 190, 203
461, 517, 521, 556, 583 Xopenex, 198, 229
Water brash, 300
Water, ultrasonic distilled, 83
Web sites, criteria, 21, 554, 576 Y
Weed pollen, 134 Yellow zone, 350, 546
Wheeze, 140, 144, 262, 267, 270, 295, 302, 310–312, Yoga, 423, 427, 434
314–316, 339, 346, 354, 446, 449, 450, 456,
529, 530, 540, 586, 614, 616, 618–620
Wheezing, 7, 8, 17–19, 21, 108, 212, 384, 446–448, 559, Z
592 Zafirlukast, 187, 188, 201, 204
Wixela Inhub, 202, 244–245 Zileuton, 187, 188, 196, 201, 204, 213
Wood smoke, 133, 140 Zones, 339, 340, 343, 350, 506–508
Workplace, 117, 133, 136, 137, 266–268, 305, 375–377, protocol for teaching, 339, 340, 342, 343
383, 405, 524, 549, 561, 601 Zyflo, 201

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Asthma

1st edition: © Authors 2005

Calgary, AB, Canada Ian Mitchell

Part I Asthma: The Fundamentals

1 Asthma and Asthma Education: The Background ���������������������� 3

2.2.5 Histology of the Airways���������������������������������������������� 43

4 Clinical Presentation of Asthma ���������������������������������������������������� 95

5.4.3 Emotion������������������������������������������������������������������������ 144

6.9 Role of Bronchial Thermoplasty in Treatment ������������������������ 206

9.8 Asthma-COPD Overlap (ACO)������������������������������������������������ 304

Part II The Role of Education

10 An Integrated Approach to Asthma Management������������������������ 335

11 Adherence ���������������������������������������������������������������������������������������� 369

12.3.4 Homeopathy���������������������������������������������������������������� 432

Part III The Effective Asthma Educator

14 Learning: Theories and Principles ������������������������������������������������ 477

14.6.1 Infancy: Trust Versus Mistrust������������������������������������ 493

15.5 Planning for Teaching ������������������������������������������������������������ 544

16.5.6 Confidentiality������������������������������������������������������������ 599

Part IV Case Studies

17 Case Studies�������������������������������������������������������������������������������������� 613

AAP Asthma Action Plan

DTCA Direct to Consumer Advertising

NHLBI National Heart, Lung and Blood Institute

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 3

education, inability to follow prescribed regi- A combination of the following contributes to

Nishimura K, Hajiro T, Oga T, Tsukino M, Sato S, Ikeda A. A comparison of

Blanco-Aparicio M, Vázquez I, Pita-Fernández S, Pértega-Diaz S, Verea-

Grammatopoulou E, Skordilis E, Koutsouki D, Baltopoulos G. An 18-item

Osborne RH, Elsworth GR, Whitfield K. The Health Education Impact

this may become clearer with genome-wide

Allergic sensitization requires assessment, and An example would be Wickman’s study of

1.6 Approaches to Asthma The process of guideline development var-

The onset of asthma most often occurs in 1.6.4 COVID-19 and Asthma

• Improved assessment and diagnosis 1.7.1 The Issues

connotations. In addition to this, many persons A key component in long-term management

1.7.2 Role of the Asthma Educator ing optimal pharmacologic therapy.” It should be

1.7.4 Essential Qualities Qualities of an asthma educator

References 14. McFadden ER Jr, Gilbert IA. Asthma. N Eng

severity in children. J Asthma. 1998;35(6):497–504. in infants of women at high risk. Cochrane

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 39

2.2 Parts of the Respiratory Tract

Fig. 2.2 Functional anatomy of the bronchial mucosa

2.2.6 Rib Cage and Diaphragm

The lungs are enclosed within what is effectively

muscle permits prolonged contraction. Increased Table 2.1 Action of epinephrine

Stretch receptors are also contained in the 2.5 Defense Mechanisms

Fig. 2.5 Process of antibody formation following exposure to a pathogen

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 55

3.4.2 Other Measures of Lung Function  77

Key Points –– These include exhaled fraction of

conducting zone of respiration made up by the

Fig. 3.1 Lung volumes

3.2.1.1 Tidal Volume (VT, Sometimes 3.2.1.4 Residual Volume (RV)

3.2.3 “Normal” or “Predicted”

Table 3.1 Measures of pulmonary function

readings is the individual’s own personal best

• To evaluate symptoms, signs, or abnormal Monitoring

• For research and clinical trials • Take several normal breaths.

Calgary, AB, Canada Ian Mitchell

Part I Asthma: The Fundamentals

1 Asthma and Asthma Education: The Background �� 3

2.2.5 Histology of the Airways�� 43

4 Clinical Presentation of Asthma �� 95

5.4.3 Emotion�� 144

6.9 Role of Bronchial Thermoplasty in Treatment �� 206

9.8 Asthma-COPD Overlap (ACO)�� 304

Part II The Role of Education

10 An Integrated Approach to Asthma Management�� 335

11 Adherence �� 369

12.3.4 Homeopathy�� 432

Part III The Effective Asthma Educator

14 Learning: Theories and Principles �� 477

14.6.1 Infancy: Trust Versus Mistrust�� 493

15.5 Planning for Teaching �� 544

16.5.6 Confidentiality�� 599

Part IV Case Studies

17 Case Studies�� 613

1.6 Approaches to Asthma The process of guideline development var-

The onset of asthma most often occurs in 1.6.4 COVID-19 and Asthma

• Improved assessment and diagnosis 1.7.1 The Issues

1.7.2 Role of the Asthma Educator ing optimal pharmacologic therapy.” It should be

1.7.4 Essential Qualities Qualities of an asthma educator

2.2 Parts of the Respiratory Tract

2.2.6 Rib Cage and Diaphragm

Stretch receptors are also contained in the 2.5 Defense Mechanisms

3.4.2 Other Measures of Lung Function 77

3.2.1.1 Tidal Volume (VT, Sometimes 3.2.1.4 Residual Volume (RV)

3.2.3 “Normal” or “Predicted”

3.3.1 FEV1, FVC, and FEV1/FVC

3.3.1.2 Forced Expiratory Flow25-75 individuals a visual depiction of their reading. It

3.3.2 Flow-Volume Loops

3.3.2.3 Criteria for Acceptability The Technologist

3.4.1.2 Diurnal Variation

3.4.1.4 Consistency in Obtaining PEF

3.4.1.5 PEF and Adherence

3.4.2.1 Fraction of Exhaled Nitric Oxide

3.5 Bronchial Challenge Testing 3.5.1 Methacholine and Histamine

3.5.2 Exercise Testing

3.5.3 Inspired Cold Air AMP induces bronchoconstriction, which is

3.8.1 Pulmonary Function Testing

3.11 Application own peak flow readings, both morning and

4.8 Diagnostic Problems in Asthma 121

4.4.1.3 Nocturnal Asthma • Significant daytime exposure (to a substance

4.4.1.4 Allergies, Asthma, 4.4.2 Occupational Asthma

4.7 ime Course of Events

4.8.1 Age-Related Asthma

4.9 ex and Gender Differences

1 8. Bierman CW. Management of exercise-

5.5.8 Medications 154

Key Points 5.1 Introduction

• The ability to exercise without symptoms. 5.2 Environmental Issues